改良经肋软骨膜入路胸腹神经阻滞与腹横肌平面阻滞用于腹腔镜袖状胃切除术的比较

Comparison of modified thoracoabdominal nerves block through perichondrial approach and transversus abdominis plane block in patients undergoing laparoscopic sleeve gastrectomy

目的比较改良经肋软骨膜入路胸腹神经阻滞(M-TAPA)与腹横肌平面阻滞(TAPB)用于病态肥胖患者腹腔镜袖状胃切除术(LSG)的镇痛效果。方法选择2020年12月至2021年8月择期行LSG患者60例,男15例,女45例,年龄18~64岁,BMI≥35 kg/m^(2),ASAⅠ或Ⅱ级。采用随机数字表法分为三组:单纯全麻组(C组)、TAPB组(T组)和M-TAPA组(M组),每组20例。全麻诱导前,T组和M组予0.25%罗哌卡因行神经阻滞操作,每侧30 ml。术后均行舒芬太尼PCIA。记录术中瑞芬太尼用量、术后48 h内镇痛泵舒芬太尼用量和术后补救镇痛例数。记录拔管后即刻及术后2、4、6、12、24、48 h静息和活动时VAS疼痛评分。记录术后首次肛门排气时间、术后首次下床活动时间。记录术后恶心呕吐、呼吸抑制等不良反应的发生情况。结果与C组比较,T组和M组术中瑞芬太尼用量、术后48 h内镇痛泵舒芬太尼用量明显减少,术后补救镇痛率明显降低,术后2、4、6、12 h静息和活动时VAS疼痛评分明显降低,术后首次肛门排气时间、术后首次下床活动时间明显缩短(P<0.05)。与C组比较,术后24、48 h M组静息和活动时VAS疼痛评分明显降低(P<0.05)。术后24、48 h C组和T组静息和活动时VAS疼痛评分差异无统计学意义。三组不良反应发生率差异无统计学意义。结论改良经肋软骨膜入路胸腹神经阻滞与腹横肌平面阻滞均可为腹腔镜袖状胃切除术后提供良好的镇痛效果,不升高不良反应发生率,且改良经肋软骨膜入路胸腹神经阻滞较腹横肌平面阻滞的镇痛持续时间更长。

Objective To compare the analgesic effect of modified thoracoabdominal nerves block through perichondrial approach(M-TAPA)and transversus abdominis plane block(TAPB)in morbidly obese patients undergoing laparoscopic sleeve gastrectomy(LSG).Methods Sixty patients scheduled for elective laparoscopic sleeve gastrectomy from December 2020 to August 2021,15 males and 45 females,aged 18-64 years,BMI≥35 kg/m^(2),ASA physical statusⅠorⅡ,were randomly divided into 3 groups:simple general anesthesia group(group C),TAPB group(group T),and M-TAPA group(group M),20 patients in each group.All the nerves blocks were guided under ultrasound before anesthesia induction with 0.25%ropivacaine 30 ml on each side,and patient-controlled intravenous analgesia(PCIA)was performed in all patierts after the surgery.The dosage of remifentanil during surgery,the dosage of sufentanil in analgesic pump within 48 hours after operation,and the number of postoperative remedial analgesia were recorded.VAS pain score at rest and activity were recorded at extubation and 2,4,6,12,24,and 48 hours after operation.The first time of anal exhaust and getting out of bed after operation were recorded.Postoperative nausea and vomiting and respiratory depression were recorded.Results Compared with group C,the dosage of remifentanil during surgery,the dosage of sufentanil in analgesic pump within 48 hours after operation and the times of rescue analgesia were significantly decreased in groups T and M(P<0.05).VAS pain scores at rest and activity were significantly lower 2,4,6,and 12 hours after operation in groups T and M than that in group C(P<0.05).The time of the first exhaust and postoperative activity were significantly earlier in groups T and M than that in group C(P<0.05).VAS pain score in group M was significantly lower than that in group C at 24 and 48 hours postoperatively(P<0.05).There was no significant difference in VAS pain scores at rest and activity between groups C and T at 24 and 48 hours postoperatively.There was no significant difference between the three groups in the rate of nausea,vomitting or respiratory depression.Conclusion Both M-TAPA and TAPB can serve well analgesia effect for patients undergoing LSG with no increase of side effects.The analgesia effect of M-TAPA block can last longer than TAPB.