Global HealthThe Efficacy and Safety of Transversus Abdominis Plane Blocks After Open Cholecystectomy in Low- and Middle-Income Countries
Introduction
Although pain management is a fundamental human right, optimal pain control may be difficult to achieve in low- and middle-income countries (LMICs) because of limited resources, lack of opioid analgesics, and differing cultural beliefs.1 The use of narcotics in LMICs is limited because of both inconsistent availability and prohibitive cost. Import restrictions are caustically stringent because of the perceived risks of addiction and abuse.2 Reported costs of importing morphine to LMICs is up to 10 times more expensive than costs in high-income countries (HICs).3 In fact, despite comprising only 17% of the world's population, HICs consume 92% of available medical morphine.3 These barriers make postoperative pain control a challenge during short-term surgical missions (STSMs) to LMICs.
Cultural perception of pain unique to LMICs can also affect treatment in these countries. Certain cultures do not vocalize pain because of a variety of reasons, including fear of showing weakness, belief that tolerance of pain is a test of faith, and concern that opioid use will lead to addiction and abuse.4, 5., 6 Unfortunately, pain may then be undertreated since admitting to pain, and requesting opioids has a negative cultural stigma. These factors may, therefore, decrease opioid use and leave patient's pain undertreated.
Adjunctive therapies to opioids, such as the transversus abdominis plane (TAP) block, present an alternative option for treating pain. However, these cultural factors could lead to nonadmittance of pain with or without adjunct. In addition, they can lead to refusal of opioids with or without adjunct, which would make oral morphine equivalents (OME), a common measure of adjunct therapy effectiveness, a null variable. Consequently, it is yet unknown the extent to which adjuncts to opioids would be effective in STSMs to LMICs.
There are many instances where well-established practices are ineffective or even harmful when used in a new population. Medical reversals are relatively significant occurrences that highlight the need for testing new medical practices in numerous patient environments.7 In addition, most tests of medical practices are conducted in HICs, which neglects potential reversals that can occur due to conditions in LMICs.7 For instance, vitamin A supplementation was previously a common intervention in LMIC interventions due to mostly assumptions about the importance of differences in HICs and LMICs.8 Although this is a logical, intuitive line of thought, more recent studies have shown no mortality benefit to vitamin A supplementation in low-income countries, thus failing to justify its cost.9 In addition, many interventions commonly used in HICs have been found to need more evidence to support their use in LMICs.10 Together, this evidence shows that extensive research is needed in novel populations until the efficacy of a potential intervention can be safely established.
The TAP block is a peripheral nerve block that has been shown to be effective in controlling postoperative pain and reducing narcotic administration in the United States and other HICs.11,12 However, although the efficacy of TAP blocks for postoperative analgesia has been clearly demonstrated in the United States and other HICs, the safety and practicality of using TAP blocks in LMICs have not been thoroughly examined. Kagwa et al. reported that this approach, when used in limited-resource settings, could allow for better pain management and become the new standard of care when performing abdominal surgery in LMICs.13 The few studies that do examine regional block utilization in limited-resource settings14,15 have not specifically investigated their use in open cholecystectomies. Therefore, more investigation is required in this specific context.
The goal of this study was to evaluate the efficacy and safety of TAP blocks as an adjunctive means of providing postoperative analgesia after an open cholecystectomy in LMICs during STSMs. We hypothesize that a TAP block is an effective adjunctive modality for postoperative pain control after open cholecystectomy in LMIC during STSMs. Furthermore, we hypothesize TAP block will decrease early intravenous (IV) narcotic consumption and decrease postoperative nausea and vomiting.12
Section snippets
Methods
We performed a retrospective chart review of patients undergoing elective open cholecystectomy during STSMs conducted by the International Surgical Health Initiative (ISHI) between 2009 and 2019. Patients were excluded if they had inadequate documentation of primary or secondary endpoints, such as visual analog scale (VAS) scores or milligrams of analgesic administered postsurgery, or if they underwent another regional block other than TAP, specifically quadratus lumborum, erector spinae, and
Results
A total of 59 open cholecystectomies were performed on ISHI missions during the study period, occurring in Peru, the Philippines, and Guatemala from the years 2009 to 2019 (Figure). One patient from the mission to Peru in 2017, who received a TAP block, was excluded because of insufficient data. Two patients from the Peru mission in 2018 and two from the Peru mission in 2015 were excluded because of receiving rectus sheath blocks. Five patients from the mission to Peru in 2019 were excluded
Discussion
Postoperative pain management is a challenging aspect of patient care during STSMs in LMICs. A lack of availability and the cost of opioids in LMICs compel surgeons and anesthesiologists to use adjunctive modalities to control pain during STSMs. One surgery performed on STSMs, which is associated with significant postoperative pain and long recovery time, is an open cholecystectomy.19 Because of this, we decided to use a TAP block, a regional anesthetic technique, to provide an alternative form
Conclusion
To our knowledge, this is the first study to examine the role and effectiveness of TAP blocks during STSMs in LMICs. The TAP block procedure is a relatively simple, efficacious, and safe pain control option that is underutilized in LMICs. TAP blocks can be used in a multimodal approach during STSMs to LMICs to provide safe postoperative analgesia after open cholecystectomy. The use of TAP blocks may reduce the risk of unwanted postoperative complications associated with opioid use on STSMs,
Acknowledgment
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors’ contributions: A.M. was involved in data collection, analysis, and writing the article. S.E. was involved in analysis, writing the article, and critical revision of the article. G.H. was involved in data collection, analysis, writing the article, and critical revision of the article. A.S., A.G., D.G., and B.P. contributed to critical revision of the article. Z.S.
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