Paragastric Autonomic Blockade to Prevent Visceral Pain After Laparoscopic Sleeve Gastrectomy
NCT ID: NCT05353426
Last Updated: 2022-04-29
Study Results
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Basic Information
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COMPLETED
NA
145 participants
INTERVENTIONAL
2021-08-13
2022-03-21
Brief Summary
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Detailed Description
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Autonomic nerve blocks have been described in the pain management literature. Specifically, celiac ganglia blocks have been reported in managing chronic pain caused by foregut malignancies or pancreatitis (11,12). In these patients, neuraxial blocks have been demonstrated to be safe and effective methods of chronic pain management. To our knowledge, however, paragastric autonomic neural blockade (PG-ANB) has not been performed as part of perioperative multimodal pain management algorithms in gastrointestinal surgery. The two proposed main mechanisms of action of this autonomic blockade are a reduction in the parasympathetic influence over the stomach, which reverses its increased muscular tone and deactivates mechanosensitive receptors in the organ wall, and blockade of the afferent sympathetic fibers that convey VP to the spinal cord (13).
In a pilot observational study involving 35 patients, we observed improvement in the severity of VP in the epigastric and retrosternal areas as well as improvement in associated autonomic symptoms following PG-ANB (14). The effect was most pronounced during the immediate postoperative period but persisted until discharge. Analgesic requirements and the presence of nausea and vomiting were also reduced. The current study was performed to further validate these preliminary findings through a randomized, double-blinded controlled trial.
Study design This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB.
Sample size Previously published data have indicated that differences of 1 to 2 points on an 11-point visual analog pain scale are clinically significant (15-17). Based on these prior studies, we chose a difference of 1 point as the minimum clinically significant difference for sample size calculation and assumed a standard deviation of 2 points. With a p-value of 0.05 and a power of 0.80, we estimated that a total of 128 patients would need to be enrolled in this study. To allow for any potential loss to follow-up, we enrolled 150 patients in the study.
Randomization and blinding Randomization was performed using sealed envelopes prepared by the data manager and stratified by institution in blocks of six. The data manager stored the randomization list containing the final treatment assignments. Only the data manager had access to the randomization list throughout the study. These sealed envelopes were placed in the patients' charts and could not be opened until the patient was in the operating room under general anesthesia. At that point, the surgeon became cognizant of the procedure to perform but did not participate in assessing the patient or collecting data. Both the patient and the investigator assessing the patient were blinded to the treatment arm assignments. The investigator evaluated the patients for vital signs, pain scores, autonomic symptoms, and analgesic requirements and recorded the information.
Data collection The patients' age, sex, body mass index, current medications, and medical and surgical history were prospectively recorded at the preoperative clinic visit during study enrollment with informed consent. An analog pain scale survey was administered by an investigator blinded to the patients' groups at 1 hour postoperatively (in the recovery room), 8 hours postoperatively, and the following morning. The investigator recorded the need for analgesics; the presence of nausea, vomiting, retching, excessive salivation, hiccups; and vital signs.
Statistical analysis Continuous outcome variables were compared with two-sample t-tests. Categorical and binary outcome variables were compared using chi-squared tests. Patient-reported pain scores were further compared using linear regression with the surgeon who operated and the location of the procedure as covariates to assess the effect of the surgeon and location on the primary outcome.
Postoperative recovery protocol All patients received proton pump inhibitors, conventional antiemetics, and a scheduled baseline analgesic such as acetaminophen (1 g intravenously every 6 hours) or dipyrone (1 g intravenously every 6 hours). The first-line rescue analgesic was a nonsteroidal anti-inflammatory drug such as diclofenac (intravenously every 12 hours) together with hyoscine butylbromide (0.2 mg intravenously every 12 hours), and the second-line rescue analgesic was tramadol (1 mg per ideal body weight intravenously every 6 hours). Tramadol was the only opioid derivative used. A popsicle was offered the afternoon after surgery, and clear fluids were started the following day. Patients were discharged from the hospital at noon the day after surgery.
Conditions
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Keywords
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Study Design
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RANDOMIZED
PARALLEL
SUPPORTIVE_CARE
DOUBLE
Study Groups
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PG-ANB Block
The paragastric lesser omentum neural block is performed with a 25-gauge needle attached to a venous catheter extension introduced through the left 12-mm port. The needle is capped during its introduction, and the cap is removed inside the abdomen using a grasper and kept under direct vision. Infiltration of 20 mL of non-diluted 0.5% bupivacaine is performed at six levels with careful aspiration preceding fluid infiltration. Four of the areas are next to the vagus nerves and branches, and two are in the vicinity of the common hepatic and left gastric arteries
Paragastric autonomic neural blockade
Paragastric autonomic neural blockade with Bupivacaine
Control
No paragastric neural block is performed in the control group. The same standard analgesic protocol consisting of acetaminophen (1 g) and morphine (3-5 mg) is used in all patients before extubation and TAP block is performed in both groups (control and experimental)
No interventions assigned to this group
Interventions
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Paragastric autonomic neural blockade
Paragastric autonomic neural blockade with Bupivacaine
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
Exclusion Criteria
* allergies to medications included in the postoperative management protocol.
* anesthetic complications related to the LSG that would alter the postoperative management protocol.
* surgical complications related to the LSG that would alter the postoperative management protocol.
18 Years
ALL
No
Sponsors
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Universidad Simón Bolívar
OTHER
Responsible Party
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Yaneth Herazo Beltran
Designated Investigator
Principal Investigators
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Jorge Daes, MD FACS
Role: STUDY_DIRECTOR
Academic Director Clinica portoazul, Barranquilla, Colombia
Locations
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Clinica Portoazul
Barranquilla, Atlántico, Colombia
Countries
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References
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Daes J, Jimenez ME, Said N, Daza JC, Dennis R. Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes Surg. 2012 Dec;22(12):1874-9. doi: 10.1007/s11695-012-0746-5.
Browning KN, Travagli RA. Central nervous system control of gastrointestinal motility and secretion and modulation of gastrointestinal functions. Compr Physiol. 2014 Oct;4(4):1339-68. doi: 10.1002/cphy.c130055.
Akinci D, Akhan O. Celiac ganglia block. Eur J Radiol. 2005 Sep;55(3):355-61. doi: 10.1016/j.ejrad.2005.03.008.
Gress F, Schmitt C, Sherman S, Ikenberry S, Lehman G. A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain. Am J Gastroenterol. 1999 Apr;94(4):900-5. doi: 10.1111/j.1572-0241.1999.01042.x.
Ruiz-Tovar J, Munoz JL, Gonzalez J, Zubiaga L, Garcia A, Jimenez M, Ferrigni C, Duran M. Postoperative pain after laparoscopic sleeve gastrectomy: comparison of three analgesic schemes (isolated intravenous analgesia, epidural analgesia associated with intravenous analgesia and port-sites infiltration with bupivacaine associated with intravenous analgesia). Surg Endosc. 2017 Jan;31(1):231-236. doi: 10.1007/s00464-016-4961-3. Epub 2016 May 13.
Iamaroon A, Tangwiwat S, Nivatpumin P, Lertwacha T, Rungmongkolsab P, Pangthipampai P. Risk Factors for Moderate to Severe Pain during the First 24 Hours after Laparoscopic Bariatric Surgery While Receiving Intravenous Patient-Controlled Analgesia. Anesthesiol Res Pract. 2019 Oct 3;2019:6593736. doi: 10.1155/2019/6593736. eCollection 2019.
Tian C, Lee Y, Oparin Y, Hong D, Shanthanna H. Benefits of Transversus Abdominis Plane Block on Postoperative Analgesia after Bariatric Surgery: A Systematic Review and Meta-Analysis. Pain Physician. 2021 Aug;24(5):345-358.
Joris J, Thiry E, Paris P, Weerts J, Lamy M. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg. 1995 Aug;81(2):379-84. doi: 10.1097/00000539-199508000-00029.
Daes J, Pantoja R, Hanssen A, et al.Paragastric, lesser omentum neural block to prevent early visceral pain after laparoscopic sleeve gastrectomy: A randomized clinical trial protocol. Revista Colombiana de Cirugia 2022;37:27-32. https://doi.org/10.30944/20117582.1017
Other Identifiers
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PRO-CEI-USB-CE-0394-00
Identifier Type: -
Identifier Source: org_study_id