Background: Enhanced recovery after surgery (ERAS) protocols have increased popularity among colorectal surgeons with being proven to reduce significantly complications, the length and cost of hospitalisation. One of key items considered is the new evidence, and modern alternatives to morphine-based analgesic regimens. While   closure loop stoma can be apparently performed as a minor surgery, these patients still suffer from postoperative severe pain due to lysis of adhesion and tension of abdominal wall. With many benefits of transversus abdominis plane (TAP) block such as reduced postoperative pain and opioid consumption, less nausea and emesis, we modified a technique of continuous TAP block (MCTAP) by inserting a catheter into TAP plane by the surgeon under direct visualization for these patients. In the basis of targeted therapy, we also used extreme low dose of local anesthetics continuous infusion. The aim of this analytic cohort study was to evaluate the analgesic effectiveness of MCTAP block compared with opioid-based analgesia in stoma reversal patients.
Methods: Patients undergoing closure loop stoma during January 2014 and December 2015 were examined and divided into two groups. Patients receiving continuous infusion of 2 ml/hr bupivacaine 0.2% over three consecutive postoperative days plus intravenous morphine injection as needed were enrolled in MCTAP group, while patients receiving only intravenous morphine injection on demand were in conventional group. Opioid consumption, numeric rating pain scores (NRPS) over three consecutive postoperative days, time to bowel function returns, and surgical recovery were recorded.
Results: A total of 42 patients underwent closure loop stoma. Of these, 20 were in MCTAP group and 22 in conventional group. Total morphine consumption in MCTAP patients was significantly lower than conventional patients (7.4, 19.59 mg respectively, P<0.005). No significant difference detected in NRPS. The median of time to first flatus was significantly less in MCTAP patients (35 and 42 hrs, respectively, P <0.05) Also, Time to first clear liquid intake was significantly less in MCTAP patients (41 and 46.5 hrs, respectively, P <0.05). Patients in MCTAP group required significantly less postoperative length of stay than those in conventional group (median = 85 and 96 hrs, respectively, P <0.01).
Conclusions: This study demonstrates that MCTAP block with low dose local anesthetics is an effective analgesic technique in closure loop stoma and may also be useful alternative analgesic remedy following stoma reversal which is in accordance with the ERAS concepts.

Analgesic effectiveness of modified continuous transversus abdominis plane block with low dose of local anesthetic continuous infusion in closure loop stoma in accordance with ERAS pathway