Author: Pierson D, et al.
A & A Practice 19(7):e02017, July 2025. doi:10.1213/XAA.0000000000002017
This Continuous Quality Improvement (CQI) study compared preoperative anterior quadratus lumborum block (aQLB; bupivacaine + dexamethasone sodium phosphate + methylprednisolone acetate) with the surgeon-placed intraoperative transversus abdominis plane block (sTAP; bupivacaine + liposomal bupivacaine) within an ERAS pathway for DIEP free-flap breast reconstruction. In 413 patients (254 sTAP before CQI vs 159 aQLB after CQI), outcomes were analyzed using stabilized inverse propensity of treatment weighting, with FDR-adjusted P values for secondary endpoints.
The aQLB cohort did not demonstrate lower opioid use versus sTAP for the primary endpoint (average daily MME), nor for total perioperative or postoperative opioid consumption. Mean pain scores were modestly higher with aQLB (+0.71; P < .001). Apparent reductions in PACU and hospital length of stay lost significance after weighting and multiple-comparison adjustment; the only secondary endpoint that remained significant was earlier ambulation (time to first ambulation ratio 0.83 [0.72–0.94]; P = .015).
Overall, preoperative ultrasound-guided aQLB appears to be an acceptable alternative to intraoperative sTAP, yielding similar opioid requirements and enabling earlier ambulation, albeit with slightly higher reported pain scores.
Key Takeaways
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Primary outcome: aQLB did not reduce average daily opioid use versus sTAP.
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Pain: aQLB was associated with slightly higher average pain scores (+0.71; P < .001).
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Length of stay: PACU and hospital LOS differences were not significant after adjustment.
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Mobility: aQLB maintained a significant benefit in earlier ambulation (ratio 0.83; P = .015).
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Practical note: aQLB can substitute for sTAP within ERAS protocols when earlier ambulation is prioritized, understanding pain scores may be marginally higher.
Thank you to A & A Practice for publishing this pragmatic CQI analysis on regional analgesia choices in DIEP reconstruction.