Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Jorge Daes, David J Morrell, Andrés Hanssen, Melissa Caballero, Elika Luque, Rafael Pantoja, Jorge Luquetta, Eric M Pauli, Jorge Daes, David J Morrell, Andrés Hanssen, Melissa Caballero, Elika Luque, Rafael Pantoja, Jorge Luquetta, Eric M Pauli

Abstract

Background: Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy.

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. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively.

Results: In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred.

Conclusion: PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Keywords: Autonomic; Block; Multimodal pain; Opioids; Paragastric; Visceral pain.

Conflict of interest statement

Jorge Daes has received honoraria from Medtronic and BD concerning hernia surgery. Andres Hanssen has received honoraria from Medtronic and Johnson & Johnson concerning hernia surgery. David J Morrell, Melissa Caballero, Elika Luque, Rafael Pantoja, Jorge Luquetta, and Eric Pauli declare that they do not have a conflict of interest concerning the publication of this manuscript.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Infiltration was performed at six levels in the fatty tissue of the paragastric area: along the vagus nerve at the esophagogastric junction, at the proximal stomach, at the mid-stomach at the distal antrum, and in the area overlying the hepatic artery
Fig. 2
Fig. 2
The area overlying the left gastric artery (close to the celiac ganglia) was infiltrated in the posterosuperior paragastric area by elevating the proximal half of the sleeve from the stomach’s neo-greater curvature
Fig. 3
Fig. 3
Flow diagram of progress through the phases of the present parallel randomized trial of two groups: enrollment, intervention allocation, follow-up, and data analysis. PG-ANB, paragastric autonomic neural blockade
Fig. 4
Fig. 4
Cumulative opioid doses administered by treatment group (each dose equivalent to 1 mg of tramadol per kg of ideal body weight) administered at 1, 8, and 24 h after laparoscopic sleeve gastrectomy

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