Ultrasound-guided TAP block holds considerable promise as a part of a balanced postoperative analgesic regimen for patients undergoing open appendicectomy.

SummarySubcostal transversus abdominis plane (TAP) catheters have been reported to be an effective method of providing analgesia after upper abdominal surgery. We compared their analgesic efficacy with that of epidural analgesia after major upper abdominal surgery in a randomised controlled trial. Adult patients undergoing elective open hepatobiliary or renal surgery were randomly allocated to receive subcostal TAP catheters (n = 29) or epidural analgesia (n = 33), in addition to a standard postoperative analgesic regimen comprising of regular paracetamol and tramadol as required. The TAP group patients received bilateral subcostal TAP catheters and 1 mg.kg−1 bupivacaine 0.375% bilaterally every 8 h. The epidural group patients received an infusion of bupivacaine 0.125% with fentanyl 2 μg.ml−1. The primary outcome measure was visual analogue pain scores during coughing at 8, 24, 48 and 72 h after surgery. We found no significant differences in median (IQR [range]) visual analogue scores during coughing at 8 h between the TAP group (4.0 (2.3–6.0 [0–7.5])) and epidural group (4.0 (2.5–5.3) [0–8.5])) and at 72 h (2.0 (0.8–4.0 [0–5]) and 2.5 (1.0–5.0 [0–6]), respectively). Tramadol consumption was significantly greater in the TAP group (p = 0.002). Subcostal TAP catheter boluses may be an effective alternative to epidural infusions for providing postoperative analgesia after upper abdominal surgery.

SummaryPosterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received fourquadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1. 0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.

There has been considerable interest and controversy around persistent postoperative pain for several years. Most of the available data arise from studies with methodological problems (especially its definition in terms of duration, severity, and effect on quality of life and function); however, more recent investigations have begun to address these issues. Although the quoted incidence varies considerably, analysis of the most conservative data shows that there is no doubt that persistent postoperative pain is a significant clinical problem and a burden to those who suffer from it. There is a wealth of literature describing factors associated with increased likelihood of persistent postoperative pain. Although it is difficult to be precise, it is clear that psychosocial factors probably play a role in some situations and that significant preoperative pain, severe immediate postoperative pain, and nerve damage are often good predictors. There are some data indicating that the incidence and severity of persistent postoperative pain can be reduced by special perioperative interventions; however, as yet, the evidence is not compelling and consistent. A reliable prevention strategy is not yet emerging from the published literature and considerably more work is required to deliver this.

No abstract

Abdominal myofascial pain syndrome is often unrecognized, especially in patients with a history of visceral inflammation. The suggested pathway may be an option in its management. Trigger point injection with steroids may have a role in the differential diagnosis of chronic abdominal pain.

Summary Accidental dural puncture following epidural insertion can cause a post‐dural headache that is defined by the International Headache Society as self‐limiting. We aimed to confirm if accidental dural puncture could be associated with persistent headache and back pain when compared with matched control parturients. We performed a prospective multicentre cohort study evaluating the incidence of persistent headache following accidental dural puncture at nine UK obstetric units. Parturients who sustained an accidental dural puncture were matched with controls who had undergone an uneventful epidural insertion. Participants were followed‐up at six‐monthly intervals for 18 months. Primary outcome was the incidence of persistent headache at 18 months. Ninety parturients who had an accidental dural puncture were matched with 180 controls. The complete dataset for primary analysis was available for 256 (95%) participants. Incidence of persistent headache at 18 months was 58.4% (52/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 18.4 (6.0–56.7), p < 0.001, after adjustment for past history of headache, Hospital Anxiety and Depression Scale (depression) and Hospital Anxiety and Depression Scale (anxiety) scores. Incidence of low back pain at 18 months was 48.3% (43/89) in the accidental puncture group and 17.4% (29/167) in the control group, odds ratio (95%CI) 4.14 (2.11–8.13), with adjustment. We have demonstrated that accidental dural puncture is associated with long‐term morbidity including persistent headache in parturients. This challenges the current definition of post‐dural puncture headache as a self‐limiting condition and raises possible clinical, financial and medicolegal consequences.

SummaryThe authors present three cases where catheters placed in the oblique sub-costal transversus abdominis plane provided prolonged analgesia after upper abdominal surgery. Patient 1 was admitted with severe sepsis following major hepatobiliary surgery. Bilateral catheters facilitated weaning from mechanical ventilation and provided adequate analgesia for 4 days. Patient 2 underwent emergency laparotomy for intestinal obstruction having refused consent for epidural analgesia. The transversus abdominis plane catheters provided a significant opioid sparing effect. A unilateral catheter offered rescue analgesia in patient 3 when the epidural catheter was displaced. We put forward a case for oblique sub-costal transversus abdominis plane catheters as an alternative to epidural analgesia after upper abdominal surgery. Transversus abdominis plane (TAP) block is a promising new regional anaesthetic technique. The indications for use of TAP block as part of a balanced anaesthetic technique are increasing [1][2][3][4][5][6][7]. However, the use of TAP catheters in the peri-operative care of the patient has not been described before. We present three patients in whom oblique sub-costal TAP catheters were used to provide significant analgesia after major upper abdominal surgery. Case 1A 77-year-old male weighing 110 kg was readmitted to the Intensive Care Unit (ICU) with signs of severe intraabdominal sepsis 2 weeks following a Whipple's procedure. His past medical history included hypertension and a right radical nephrectomy for renal cell carcinoma. A CT scan of his abdomen revealed an intraperitoneal collection. Therefore, he underwent an emergency laparotomy at which a completion pancreatectomy and washout of the peritoneal cavity was performed. He received a 10-unit transfusion of packed red blood cells intra-operatively. The patient was ventilated using invasive positive pressure ventilation postoperatively and initially required a high dose noradrenaline infusion (2 mg.h )1 ) to maintain an adequate arterial blood pressure. On day two after his emergency surgery he had made sufficient clinical improvement to consider weaning him from artificial ventilation. However, there was a 51-cm rooftop incision across the upper abdomen and three peritoneal drains were in situ. As the patient had expressed a wish prior to surgery not to have an epidural sited, bilateral oblique sub-costal TAP catheters were inserted, local anaesthetic solution was administered and the morphine infusion was switched off. The patient was extubated 52 h after surgery. Visual analogue scores (VAS) at rest and on coughing were measured at 6 hourly intervals after extubation for 48 h. The average VAS at rest was 0 ⁄ 10 and on coughing was 2 ⁄ 10. The patient received 20 ml of 0.5% bupivacaine every 12 h. Regular paracetamol was administered but he did not require any opioids throughout the duration of his ICU stay. The TAP catheters were used for 4 days to provide analgesia and enabled the patient to undergo effective chest