|Year : 2022 | Volume
| Issue : 1 | Page : 33-36
Postoperative analgesic efficacy of quadratus lumborum block in patients undergoing laparoscopic cholecystectomy: A retrospective study
Sunita Kulhari1, Chetna Shamshery2, Suruchi Ambasta2, Anil Agarwal2, Rajneesh Kumar Singh3, Monalisa Srivastava4
1 Department of Anaesthesiology, Asian Super Speciality Hospital, Jaipur, Rajasthan, India
2 Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Anaesthesiology, Medanta Hospital, Lucknow, Uttar Pradesh, India
|Date of Submission||13-Nov-2021|
|Date of Decision||09-Dec-2021|
|Date of Acceptance||02-Jan-2022|
|Date of Web Publication||25-Apr-2022|
Dr. Suruchi Ambasta
Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Patients undergoing laparoscopic cholecystectomy (LC) often complain of pain in the postoperative period despite intravenous analgesic administration. Systemic analgesia is also associated with side effects such as postoperative nausea and vomiting, thus adding to patient's discomfort. Posterior quadratus lumborum (QL) block has been studied to provide adequate analgesia in this set of patients. We retrospectively studied the efficacy of posterior QL block in LC patients and assessed them for chronic pain. Methods: Records of patients meeting inclusion criteria were taken. Standard multimodal analgesia as per the institute protocol was performed in all patients. Posterior QL block was performed under ultrasound guidance in test group, while control group received parenteral analgesia alone. Measurements: Static and dynamic Numeric Rating Scale (NRS) were measured at different time intervals during the first 24 postoperative h and time to rescue analgesia was noted. Assessment of chronic pain was done at the same time for all the patients. Side effect profile of both the groups was compared. Results: Static and dynamic pain scores were compared between block and control groups at immediate postoperative time period, 3 h, 12 h, and 24 h and statistically significant difference was noted with lower scores in test group as compared to control group at all four time points (P < 0.05). None of the patients in test group suffered chronic pain, while 33.3% patients in control group had chronic pain. Conclusion: Posterior QL block is an effective analgesia option for LC patients with less incidence of side effects. It should be performed more frequently as it is effective in reducing acute and probably chronic pain too in LC patients.
Keywords: Analgesia, laparoscopic cholecystectomy, pain, quadratus lumborum block
|How to cite this article:|
Kulhari S, Shamshery C, Ambasta S, Agarwal A, Singh RK, Srivastava M. Postoperative analgesic efficacy of quadratus lumborum block in patients undergoing laparoscopic cholecystectomy: A retrospective study. Indian J Pain 2022;36:33-6
|How to cite this URL:|
Kulhari S, Shamshery C, Ambasta S, Agarwal A, Singh RK, Srivastava M. Postoperative analgesic efficacy of quadratus lumborum block in patients undergoing laparoscopic cholecystectomy: A retrospective study. Indian J Pain [serial online] 2022 [cited 2022 May 24];36:33-6. Available from: https://www.indianjpain.org/text.asp?2022/36/1/33/343834
| Introduction|| |
Cholecystectomy is one of the most common intra-abdominal surgeries and laparoscopy is the preferred choice. Almost 17%–41% of patients who undergo laparoscopic cholecystectomy (LC) complain of insufficient pain relief due to port-site insertion, peritoneal stretching by intra-abdominal gas insufflation, surgical interventions into the hepatorenal recess, residual intraperitoneal CO2, and viscera handling., Various modalities including intravenous nonsteroidal anti-inflammatory drugs, opioids, local anesthetic infiltrations, and regional anesthesia techniques including epidurals (thoracic) and truncal blocks such as transversus abdominis plane (TAP) block can be used for the treatment of postoperative pain. Systemic opioids or other parenteral drugs can provide effective pain relief, but their administration has a well-defined risk of side effects.,,
Preventive analgesia is a promising strategy for postoperative pain relief and the efficacy improves using multimodal approach. Recently with the rise in enhanced recovery after surgery, nerve blocks have become the key link in the armamentarium of multimodal analgesic regimens.
Quadratus lumborum (QL) block and TAP block are frequently performed techniques to achieve analgesia in abdominal surgery. Postoperative pain in abdominal surgery is better managed by QL block as it results in more extensive sensory blocks than TAP block (T10–L3 vs. T10–T12, respectively).
TAP block and local anesthetic infiltration at the port sites cover only incisional pain and not visceral pain. QL block can possibly take care of both somatic and visceral pain.
QL block using the posterior approach may give analgesia between T7 and T11. Blanco in 2007 started administrating QL block where anesthetic is injected adjacent to the anterolateral aspect of the QL muscle and its fascia, blocking the posterior abdominal wall. The blockade occurs at higher level (T7-L1), thus providing adequate analgesia for both upper and lower abdominal surgery. Analgesic effect of QL block is mainly through the thoracolumbar fascia (TLF) which is a complex tubular structure formed by connective tissue. Local anesthetics can spread through the TLF to the paravertebral space to generate an indirect paraspinal block.,, Therefore, QL block is effective for both visceral pain and abdominal incision pain.
We performed this retrospective study with the primary objective to compare the efficacy of posterior QL block as a part of multimodal analgesia with that of parenteral analgesia alone in cases undergoing LC. The secondary objective of the study was to evaluate the incidence of chronic pain in these groups of patients.
| Materials and Methods|| |
We obtained ethical clearance from the institute ethical committee (IEC: 2021-170-IP-EXP-40).
This was a retrospective, observational single-center study in patients who underwent LC from January 2020 to December 2020.
The hospital records of the patients from our tertiary care institute were reviewed.
Cases and controls were matched in terms of age, sex, and disease and met the inclusion criteria which were patients of either gender, aged between 18 and 60 years undergoing LC, and belonged to American Society of Anesthesiologists physical status I, II with surgical duration <2 h. Patients receiving posterior QL block were included as cases, while those managed by parenteral analgesia alone formed the control group.
Our study consisted of a total of 19 patients undergoing LC with 10 patients who had received QL block [Figure 1]. All the blocks were performed immediately after intubation. USG guided block with the curvilinear probe was performed in lateral decubitus position. The probe was placed in the midaxillary line cranially to the iliac crest and moved dorsally until QL muscle was visualized. 22-gauge 9 cm needle was inserted in-plane from anterior to posterior direction. The tip of the needle was advanced toward the posterior border of the QL, between the QL and the latissimus dorsi muscles. Fifteen milliliter of 0.25% bupivacaine was given at this point. The same procedure was repeated on the other side.
All the patients received parenteral analgesia in the perioperative period as per our institute Acute Pain Services protocol which includes injection paracetamol 1 g iv thrice a day) and injection diclofenac 75 mg twice a day with injection tramadol 1 mg/kg as rescue analgesia dose. All patients received injection fentanyl 2 μg/kg during induction followed by 1 μg/kg every hour intraoperatively.
Demographic data, NRS (Numeric Rating Scale) scores (0–10, 0 means no pain, 10 means worst pain imaginable) for acute static and dynamic pain at immediate postoperative, 3, 12, and 24 h, rescue analgesia requirement, any adverse events, and chronic pain on July 15, 2021 were recorded. Static and dynamic pain scores were noted with patients at rest or with deep breathing and coughing, respectively.
The recall bias was neutralized by directly retrieving data from the hospital records for acute pain scores and investigating the chronic pain at the current time.
| Results|| |
Of the 36 patients operated during the said year for LC, 19 patients met the inclusion criteria. There was no difference between age, gender, ASA classification, or other demographics such as height and weight between groups (P < 0.05) [Table 1].
|Table 1: Distribution of demographic and other variables between experimental group and controls (n=19)|
Click here to view
In this study, a total of 19 patients were studied, with 10 patients in cases and 9 in control group. In QL group, the median age of the patients was 52.5 years, whereas in controls, it was 39.5 years (P > 0.05). Similarly, insignificant differences in weight (P > 0.05) were seen in both the groups. 260 ± 42.43 min was the time for the need of rescue analgesia (P < 0.05) in the QL group as compared to 120 ± 34.64 min in the control group (P < 0.05). Static pain and dynamic pain were compared between block and control groups at immediate postoperative time period, 3 h, 12 h, and 24 h. There were significant lower values of the static and dynamic NRS pain score in block group as compared to control group at all four time points [Figure 2]. No chronic pain was observed in QL group (7/10 responded) whereas 3 patients (9/9 responded) had pain in control group (33.33%) though the NRS score was ≤4. One patient in control group with NRS of 9 had pain due to uterine fibroids so she was excluded from the study. No side effects were noted in any patient [Table 1].
|Figure 2: Mean static and dynamic NRS pain scores in test and control groups at different time points|
Click here to view
| Discussion|| |
This retrospective study revealed a significant decrease in static and dynamic pain scores in immediate postoperative, 3 h, 12 h, and 24 h postoperative period with almost double time to rescue analgesia in the block group as mentioned in the results. The study also revealed that no patient reported chronic pain in the block group, whereas 33.33% patients of the control group suffered chronic pain, although of mild intensity.
An in-plane approach is generally used to perform posterior QL block in either anterior-to-posterior or posterior-to-anterior direction wherein local anesthetic is deposited between the QL and erector spinae muscle. The injectate spreads along the intertransverse area of middle TLF.
Our study showed better static and dynamic pain control after LC at different time points in the group given posterior QL block compared to the control group. This is in concordance with the previously conducted studies wherein posterior QL block has shown reduced postoperative pain scores after laparoscopic gynecological surgery and reduced rescue analgesia requirements after lower abdominal surgery.,
The analgesic effect is as good as the one achieved by opioids, and there are no unwanted opioid effects such as nausea and vomiting. In our study, time to rescue analgesia was almost double in the test group. No side effects were reported in either group.
Abdominal truncal blocks are very frequently performed these days for laparoscopic surgeries. TAP blocks have been used with proven efficacy for a long time, while QL block is relatively new. The anatomical connection of the fascia transversalis with endothoracic fascia is the reason local anesthesia reaches paravertebral space and this has been proposed as the potential mechanism in the study in which posterior QL block has been applied. In another study by Ishio et al., visual analog scale (VAS) on movement and at rest was found lower after posterior QL block than the placebo.
Risk of intraperitoneal injection and bowel injury is also reduced with QL block, as this muscle lies between peritoneum and the needle tip.
Ökmen et al. also documented reduced VAS scores during rest and activity at all postoperative times, and the values of PCA tramadol consumption at the postoperative 6th and 12th h were found to be significantly lower in the posterior and lateral QL group.
Postcholecystectomy chronic pain has an incidence of about 20%. We also tried to assess all our patients telephonically for the occurrence of chronic pain once on July 15, 2021, at a single point of time. The duration for assessment of chronic pain after surgery was variable among the patients between 6 and 18 months. As all the patients did not respond, we could not derive any statistically significant conclusions. None of the seven patients in the block group complained of chronic pain; hence, re-emphasizing the fact that if effective analgesia is covered perioperatively, it is likely to prevent the occurrence of chronic pain.
Our study has the following limitations. The sample size achieved for our study was small because the number of elective cases was reduced drastically during COVID times. The follow-up time postoperatively in our study was only 24 h. Although we followed the patients telephonically for chronic pain at a single point of time, but 25% of patients in the block group did not respond so the clinical relevance could not be established. The follow-up reporting time of the chronic pain was variable among the patients (range 6 months–18 months). As per the available data, side effects such as nausea, vomiting, or hypotension were not recorded in any of the cases or control groups.
Further studies with higher number of patients may be needed to conclude its effect on chronic pain. Although the time for rescue analgesia was available in the records, amount of tramadol consumption was not mentioned.
| Conclusion|| |
Posterior QL is effective in reducing the acute and may possibly reduce chronic pain scores of patients compared to parenteral analgesia alone in LC surgery. Ultrasound imaging is easy, as described in previous studies, and incidence of side effects is also very low, making it a favorable option.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Comitalo JB. Laparoscopic cholecystectomy and newer techniques of gallbladder removal. JSLS 2012;16:406-12.
Bisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Ann R Coll Surg Engl 2001;167:84-96.
McDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al
. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: A randomized controlled trial. Anesth Analg 2008;106:186-91.
Niraj G, Searle A, Mathews M, Misra V, Baban M, Kiani S, et al.
Analgesic efficacy of ultrasound-guided transversus abdominis plane block in patients undergoing open appendicectomy. Br J Anaesth 2009;103:601-5.
Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al.
Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: A meta-analysis. Anesthesiology 2005;103:1079-88.
Cho JS, Kim HI, Lee KY, Son T, Bai SJ, Choi H, et al.
Comparison of the effects of patient-controlled epidural and intravenous analgesia on postoperative bowel function after laparoscopic gastrectomy: A prospective randomized study. Surg Endosc 2017;31:4688-96.
Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev 2018;8:CD010434.
Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. JAMA Surg 2017;152:691-7.
Liu X, Song T, Chen X, Zhang J, Shan C, Chang L, et al.
Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: A systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2020;20:53.
Urits I, Ostling PS, Novitch MB, Burns JC, Charipova K, Gress KL, et al.
Truncal regional nerve blocks in clinical anesthesia practice. Best Pract Res Clin Anaesthesiol 2019;33:559-71.
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;41:757-62.
Sa M, Cardoso JM, Reis H, Esteves M, Sampaio J, Gouveia I, et al.
Quadratus lumborum block: Are we aware of its side effects? A report of 2 cases. Rev Bras Anestesiol 2018;68:396-9.
Elsharkawy H, El-Boghdadly K, Barrington M. Quadratus lumborum block: Anatomical concepts, mechanisms, and techniques. Anesthesiology 2019;130:322-35.
Ishio J, Komasawa N, Kido H, Minami T. Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery. J Clin Anesth 2017;41:1-4.
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;42:674-9.
Ökmen K, Metin Ökmen B, Sayan E. Ultrasound-guided lateral versus posterior quadratus lumborum block for postoperative pain after laparoscopic cholecystectomy: A randomized controlled trial. Turk J Surg 2019;35:23-9.
Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: Analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med 2016;41:146-50.
Macrae WA. Chronic pain after surgery. Br J Anaesth 2001;871:88-9.
Campiglia L, Consales G, De Gaudio AR. Pre-emptive analgesia for postoperative pain control: A review. Clin Drug Investig 2010;30 Suppl 2:15-26.
[Figure 1], [Figure 2]