Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study

Overview

Journal Cureus

Specialty Biomedical Engineering

Date 2023 Dec 22

PMID 38130508

Authors

Paul S Lee

Laurie L Brunette

Intira Sriprasert

Mohamed Eloustaz

Rasika Deshpande

Crystal Adams

Laila Muderspach

Lynda Roman

Shane Dickerson

Michael P Kim

Affiliations

Soon will be listed here.

Abstract

Study Objective: This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery.

Design And Setting: This retrospective cohort study was performed in a tertiary care hospital.

Patients: A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study.

Interventions: The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge.

Measurements And Main Results: The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block.

Conclusions: The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

References

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):757-762. DOI: 10.1097/AAP.0000000000000495. View

Nelson G, Altman A, Nick A, Meyer L, Ramirez P, Achtari C . Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol. 2016; 140(2):323-32. PMC: 6038804. DOI: 10.1016/j.ygyno.2015.12.019. View

Elsharkawy H, El-Boghdadly K, Barrington M . Quadratus Lumborum Block: Anatomical Concepts, Mechanisms, and Techniques. Anesthesiology. 2019; 130(2):322-335. DOI: 10.1097/ALN.0000000000002524. View

Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer L . Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer. 2019; 29(4):651-668. DOI: 10.1136/ijgc-2019-000356. View

Cavallaro P, Milch H, Savitt L, Hodin R, Rattner D, Berger D . Addition of a scripted pre-operative patient education module to an existing ERAS pathway further reduces length of stay. Am J Surg. 2018; 216(4):652-657. DOI: 10.1016/j.amjsurg.2018.07.016. View

Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M . Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2013; 38(6):1531-41. DOI: 10.1007/s00268-013-2416-8. View

Chapman J, Roddy E, Ueda S, Brooks R, Chen L, Chen L . Enhanced Recovery Pathways for Improving Outcomes After Minimally Invasive Gynecologic Oncology Surgery. Obstet Gynecol. 2016; 128(1):138-144. DOI: 10.1097/AOG.0000000000001466. View

Bisch S, Jago C, Kalogera E, Ganshorn H, Meyer L, Ramirez P . Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol. 2021; 161(1):46-55. DOI: 10.1016/j.ygyno.2020.12.035. View

Chow S, Karam A . Role of sentinel lymph node biopsy for gynecologic cancers. Curr Opin Obstet Gynecol. 2021; 34(1):15-19. DOI: 10.1097/GCO.0000000000000766. View

10.

Huang L, Zheng L, Zhang J, Zhu X, Pan L, Zhang Y . Transmuscular quadratus lumborum block versus oblique subcostal transversus abdominis plane block for analgesia in laparoscopic hysterectomy: a randomised single-blind trial. BMJ Open. 2021; 11(8):e043883. PMC: 8356166. DOI: 10.1136/bmjopen-2020-043883. View

11.

Kalogera E, Dowdy S . Enhanced Recovery Pathway in Gynecologic Surgery: Improving Outcomes Through Evidence-Based Medicine. Obstet Gynecol Clin North Am. 2016; 43(3):551-73. DOI: 10.1016/j.ogc.2016.04.006. View

12.

Kay A, Venn M, Urban R, Gray H, Goff B . Postoperative narcotic use in patients with ovarian cancer on an Enhanced Recovery After Surgery (ERAS) pathway. Gynecol Oncol. 2019; 156(3):624-628. DOI: 10.1016/j.ygyno.2019.12.018. View

13.

. ACOG Committee Opinion No. 750: Perioperative Pathways: Enhanced Recovery After Surgery. Obstet Gynecol. 2018; 132(3):e120-e130. DOI: 10.1097/AOG.0000000000002818. View

14.

Stone R, Carey E, Fader A, Fitzgerald J, Hammons L, Nensi A . Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper. J Minim Invasive Gynecol. 2020; 28(2):179-203. DOI: 10.1016/j.jmig.2020.08.006. View

15.

Barber E, Van Le L . Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology. Obstet Gynecol Surv. 2015; 70(12):780-92. PMC: 4683417. DOI: 10.1097/OGX.0000000000000259. View

16.

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. DOI: 10.1097/AAP.0000000000000349. View

17.

Matanes E, Eisenberg N, Amajoud Z, Gupta V, Yasmeen A, Ismail S . Sentinel Lymph Node Sampling as an Alternative to Lymphadenectomy in Patients With Endometrial Cancer and Obesity. J Obstet Gynaecol Can. 2021; 43(10):1136-1144.e1. DOI: 10.1016/j.jogc.2021.04.014. View

18.

Nelson G, Altman A, Nick A, Meyer L, Ramirez P, Achtari C . Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol. 2015; 140(2):313-22. DOI: 10.1016/j.ygyno.2015.11.015. View

19.

Jadon A, Ahmad A, Sahoo R, Sinha N, Chakraborty S, Bakshi A . Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: A prospective randomised double-blinded study. Indian J Anaesth. 2021; 65(5):362-368. PMC: 8202790. DOI: 10.4103/ija.IJA_1258_20. View

20.

Dam M, Moriggl B, Hansen C, Hoermann R, Bendtsen T, Borglum J . The Pathway of Injectate Spread With the Transmuscular Quadratus Lumborum Block: A Cadaver Study. Anesth Analg. 2017; 125(1):303-312. DOI: 10.1213/ANE.0000000000001922. View