Repeat quadratus lumborum blocks in pancreatectomy: needed or not?

In the recently published article in Gland Surgery by Fields et al. (1), investigators quantified the effect of a two-time quadratus lumborum (QL) regional block on pain outcomes after open pancreatectomy, with a single injection QL block performed in the comparator group. The primary outcome was the percentage of patients who were discharged without an opioid prescription. Pertinent secondary outcomes included the number of patients refilling an opioid prescription at 30 days and at 3 months.

The QL block was first described in the year 2007 by Rafael Blanco, who used radiologic computed tomography scans to analyze anatomic spread on cadavers and later studied analgesic effects of the block on patients undergoing abdominoplasty (2). Case reports in 2013 solidified the nomenclature of this technique as the QL block. In the transversus abdominis plane (TAP) block, which is another commonly employed regional anesthesia procedure, the deposition of local anesthetic spreads into the fascial plane between the transversus abdominis muscle and the internal oblique muscle, anesthetizing the somatic nerve branches exiting from thoracic dermatomal level 6 and lumbar dermatomal level 1 (T6-L1) is targeted. Additionally, by administering local anesthetic posterior to the TAP plane and superficial to the QL muscle, the solution may spread towards the dorsal rami of these dermatomes, and therefore provide coverage for visceral pain as well (3). An early case series on patients undergoing laparoscopic ovarian surgery demonstrated over 24 hours of analgesia when a QL block was performed with 0.375% ropivacaine (4).

Fields and colleagues used a bilateral four-quadrant technique for their patient cohort, which combined a TAP block with a QL block. By performing the block in this manner, the degree of local anesthetic spread is likely to be greater, maximizing the chance that local anesthetic will contact the appropriate targets. There is thought to be a dual mechanism of action in which there is a muscle relaxation effect combined with direct blockade of nerve transmission. Because of anatomic variation between patients as well as limitation of local anesthetic spread through the desired fascial plane, fascial plane blocks such as the QL block are considered “patchy”—in other words, there is variation in the degree and location of analgesia even the block procedure is performed perfectly (5). Because of this, systematic reviews and meta-analyses on the QL block have mixed results (6,7).

In the control arm, 52% of the patients were discharged with no opioids, and in the experimental arm, 36.5% of the patients were discharged with no opioids. These results are a stark contrast to the historical baseline at this institution in which patients on average were discharged with 300 oral morphine equivalents. “Enhanced recovery after surgery (ERAS)” has been implemented in over 20 countries internationally, and the combination of interventions together could have a synergistic effect that leads to reduction in length of hospital stay and increased patient satisfaction (8,9). ERAS also methodically eliminates interventions that could increase length of stay, such as intravenous opioid patient-controlled analgesic infusions and prolonged epidural analgesia, which could lead to a delay in ambulation.

Long-acting formulations of local anesthetic like liposomal bupivacaine (EXPAREL) were developed by Pacira Pharmaceuticals (Parsippany, NJ, USA) and became available in the USA in 2012 (10). The product’s formulation encapsulates free bupivacaine into liposomal vesicles. In live conditions, the vesicles degrade at a fixed rate, resulting in constant output of free bupivacaine over 72 hours. Early studies showed superior outcomes when compared to plain bupivacaine for shoulder surgery, obstetric cesarean section, and bunionectomy (11-13). However, larger studies mostly demonstrate non-inferiority (14,15).

The authors of this study were diligent about measuring relevant outcomes, which include opioid prescription upon discharge, persistent opioid use, and overall level of comfort as indicated by a quantitative pain scale. While opioid consumption and pain scores are easily measured and translated into scientific investigation, these metrics only serve as markers to end goals that signify real results that affect the patients and the supporting hospital systems, which include hospital length of stay, incidence of postoperative complications, patient satisfaction, and quality of life (16). Long-lasting positive impacts from the addition of regional anesthesia techniques have been demonstrated through metrics such as reduction in breast cancer recurrence with paravertebral block, reduced mortality in total knee and hip replacement with spinal anesthesia, and increased long-term patency of arteriovenous fistula with a brachial plexus block (17-19). However, these results have not been replicated in repeat studies asking similar questions, which begs the question of large-scale reproducibility over many hospital systems and over the course of time.

The authors’ institution is to be applauded to the ability to offer not only one QL block, but the ability to repeat the block prior to discharge. Most institutions do not have the expertise, nor the staffing resources to offer this service. The QL block is considered an advanced technique and is not considered a “need to know” block in anesthesiology training programs (20). Fields and colleagues showed a modest benefit in their patient cohort, but ultimately a hospital system will need to determine if this benefit has enough impact to make changes to their own system.

In conclusion, the authors’ institution has made a true impact on their patients through their intentional implementation of an ERAS protocol and their utilization of regional anesthesia expertise that allowed for repeat nerve block procedures with long-acting local anesthetic.

Acknowledgments

AI disclosure: ChatGPT, version 4.0, was used to locate and format references.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0182/coif). B.W.T. received an honorarium payment from the American Board of Anesthesiologists; received support to attend meetings by the University of North Carolina Department of Anesthesiology; owns individual stock in Medtronic, PLC; and is a co-owner of Rhythm Management, LLC. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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