Cengiz Kaya

Background: Although widely performed, video-assisted thoracoscopic surgery (VATS) is associated with significant postoperative pain. Thoracic paravertebral block (TPVB) is a guideline-favored regional technique, while intrathecal morphine (ITM) is a technically less demanding and more widely applicable neuraxial alternative. We hypothesized that ITM would provide analgesic efficacy non-inferior to TPVB in terms of 24-hour intravenous morphine milligram equivalents (IV-MME). Methods: This was a prospective, randomized, controlled, observer-blinded non-inferiority trial. Adults undergoing elective VATS were randomized 1:1 to TPVB (0.25% bupivacaine, 0.4 mL/kg+epinephrine 1:400,000) or ITM (5 mcg/kg based on ideal body weight). The primary endpoint was 24-hour IV-MME (intraoperative opioids excluded). Secondary endpoints included 12-hour IV-MME, pain (Numeric Rating Scale at rest/activity), rescue analgesia, time to first opioid demand, 15-item Quality of Recovery, safety (postoperative nausea/vomiting, pruritus, respiratory depression), and 30-day complications. The prespecified non-inferiority margin was 5.05 mg. Analyses followed intention-to-treat with per-protocol sensitivity. Results: Of 82 screened, 72 were randomized (ITM n=36; TPVB n=36); 2 TPVB conversions to thoracotomy were excluded from the per-protocol set (n=70). For the primary endpoint, the median difference (ITM–TPVB) in 24-hour IV-MME was 6.5 mg (95% CI 1 to 17; p=0.009) in intention-to-treat and 9.0 mg (95% CI 2 to 18; p=0.002) in per-protocol; in both analyses, the upper CI bound exceeded 5.05 mg, and non-inferiority was not met. Individual 24-hour and 12-hour IV-MME favored TPVB; rescue analgesia was more frequent with ITM (21/36 vs 12/36; p=0.033). Pain outcomes, quality of recovery scores, and time to first opioid demand were similar, with no respiratory depression. Although mild 30-day Clavien-Dindo grade I events differed between groups, no apparent clinically meaningful safety signal was observed. Conclusions: ITM did not demonstrate non-inferiority to TPVB for 24-hour IV-MME; TPVB was associated with lower systemic opioid use, while pain outcomes were similar. Trial registration number: NCT07126483 .

The anterior quadratus lumborum block (aQLB) is a fascial plane block targeting the interfascial plane between the quadratus lumborum and psoas major muscles, aiming to achieve both somatic and visceral analgesia through potential spread of local anesthetic toward the thoracolumbar nerve roots. Despite years of clinical use and a growing body of randomized trials across different surgical settings, uncertainty remains regarding its mechanisms of action, patterns of local anesthetic spread, and overall clinical effectiveness. This scoping review aimed to systematically map and synthesize the available evidence on aQLB and identify key knowledge gaps relevant to clinical practice and future research. A comprehensive search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Library was conducted from database inception to February 14, 2026. The search terms included variations of aQLB and related terminology. Only randomized controlled trials were included in this review. A total of 1174 records were identified, of which 360 underwent full-text assessment, and 119 randomized controlled trials were included. Most studies were conducted in Asia (63%) and involved adults (92%). Abdominal and urological procedures were the most commonly studied surgical indications (56%), followed by orthopedic surgeries (26%) and obstetric-gynecological procedures (17%). Multiple aQLB variants have been reported, including transmuscular, subcostal anterior, supra-arcuate ligament, and lateral arcuate ligament approaches. Comparators included sham or no block, wound infiltration, transversus abdominis plane block, erector spinae plane block, paravertebral block, neuraxial techniques, and other regional techniques. Across studies, the aQLB generally reduced postoperative pain scores, opioid consumption, and postoperative nausea and vomiting. However, the findings were heterogeneous and varied by surgical procedure and study design. The available literature suggests that aQLB may provide effective postoperative analgesia and opioid-sparing benefits across different surgical procedures. However, inconsistent findings among studies, the limited number of well-designed randomized controlled trials, and substantial heterogeneity across surgical populations restrict the strength of the current conclusions. Moreover, the deep anatomical location of the block, technical complexity, and potential risks should be considered when evaluating its role in routine clinical practice.

Background Postoperative pain after laparoscopic colorectal surgery (LCS) is complex, involving both somatic and visceral components. Anterior subcostal quadratus lumborum block (QLB) is a novel regional technique that may provide dual analgesic coverage. Objective To evaluate the analgesic efficacy of ultrasound-guided anterior subcostal QLB in patients undergoing LCS. Design This prospective, randomized, observer-blinded trial included 60 adults scheduled for elective LCS at a university hospital between October 2024 and May 2025. Patients were randomly allocated to receive either bilateral anterior subcostal QLB or no regional anesthesia or local anesthetic infiltration (control). Main outcome measures The primary outcome was cumulative intravenous morphine milligram equivalent consumption at 24 hours postoperatively. Secondary outcomes included 12 hours intravenous morphine milligram equivalent consumption, pain scores (at rest and activity), time to first demand for patient-controlled analgesia (PCA), rescue analgesic/antiemetic use, block-related complications and recovery parameters. Results Data from 55 patients were analyzed (QLB (n=27); control (n=28)). The median 24-hour intravenous morphine milligram equivalent consumption was significantly lower in the QLB group than that in the control group (15 mg (Q1–Q3, 6.5–22 mg) vs 24.3 mg (Q1–Q3, 20.3–30.3 mg); p=0.006). Pain scores at all time points were significantly lower in the QLB group (pConclusions The anterior subcostal QLB was associated with reduced postoperative opioid use, lower pain scores and a lower incidence of postoperative nausea–vomiting after LCS, suggesting a potential role in enhancing recovery. Trial registration number NCT06653439; registration date: 20 October 2024.

Background Laparoscopic sleeve gastrectomy (LSG) is associated with significant postoperative pain despite being minimally invasive. External oblique intercostal block (EOIB) has emerged as a novel regional anesthesia technique targeting upper abdominal wall innervation. In this systematic review and meta-analysis with trial sequential analysis (TSA), we aimed to systematically assess the analgesic efficacy of EOIB in patients undergoing LSG, focusing on opioid consumption, pain scores, rescue analgesia use, and recovery outcomes. Methods We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (from inception to until 22 May 2025). The primary outcome was 24-h opioid consumption. Secondary outcomes included pain scores, postoperative nausea and vomiting (PONV), and rescue analgesic use. Risk of bias was assessed using RoB 2, and the certainty of evidence was evaluated using the GRADE approach. Results Four RCTs (n = 249) were included. EOIB significantly reduced 24-h morphine milligram equivalent (MME) consumption (MD − 12.76 mg; 95% CI − 16.76 to − 8.77; p < 0.001). EOIB also lowered postoperative pain scores and decreased rescue analgesic use (OR 0.20; 95% CI 0.09–0.45). PONV incidence was reduced, but not statistically significant. TSA demonstrated that the current evidence is sufficient to confirm a statistically significant effect, with no further trials required. Conclusions EOIB appears to be a safe and effective component of multimodal analgesia in LSG, with TSA results supporting the robustness of current evidence.

Aim: Awake deep brain stimulation (DBS) surgery requires the patient to remain conscious for optimal electrode placement through intraoperative neurophysiological monitoring. However, hypertension during awake DBS poses significant clinical challenges, potentially compromising surgical accuracy and patient safety. Nicardipine and esmolol are both used for intraoperative blood pressure control, but their comparative efficacy in awake DBS remains unclear. The aim of this study was to compare the effectiveness of nicardipine and esmolol in controlling intraoperative blood pressure during awake DBS surgery under monitored anesthesia care. Material and Methods: This retrospective study evaluated patients who underwent awake DBS surgery under MAC between January 2020 and April 2025. Forty adult patients experiencing intraoperative hypertension (systolic arterial pressure [SAP] ≥150 mmHg) were included and divided into two groups based on the antihypertensive agent administered: nicardipine (n = 20) or esmolol (n = 20). Hemodynamic parameters, antihypertensive requirements, and intraoperative complications were compared between the groups. Results: Mean intraoperative SAP was significantly lower in the nicardipine group compared to the esmolol group (121.9 ± 2.6 mmHg vs. 127.9 ± 3.5 mmHg, p = 0.04). Although the frequency of hypertensive episodes tended to be lower with nicardipine, this did not reach statistical significance (15.9% ± 3.6 vs. 26.1% ± 4.1, p = 0.21). Esmolol resulted in significantly lower heart rates (69.2 ± 2.8 bpm vs. 87.9 ± 2.0 bpm, p = 0.01) but required higher doses of rescue antihypertensives (glyceryl trinitrate: 53.1 ± 5.8 mg vs. 25.8 ± 1.2 mg, p < 0.001). No major intraoperative complications or conversions to general anesthesia occurred in both groups. Conclusions: Nicardipine provided more effective and stable intraoperative blood pressure control than esmolol during awake DBS surgery, reducing the need for additional antihypertensive medications. Both agents were safely administered without compromising patient cooperation or neurophysiological monitoring. Therefore, nicardipine may be preferable due to the less need for rescue antihypertensive treatment.

Background Intrathecal morphine (ITM) offers effective analgesia after laparoscopic nephrectomy but may cause side effects. The anterior subcostal quadratus lumborum (QL) block has been proposed as a safer alternative. This study evaluated whether anterior subcostal QL block is non-inferior to ITM in reducing postoperative opioid use. Methods This single-center, randomized, observer-blinded, non-inferiority trial allocated 80 adult patients undergoing elective laparoscopic nephrectomy to receive single-injection unilateral anterior subcostal QL block (0.25% bupivacaine (0.4 mL/kg) containing epinephrine 1:400,000) or spinal anesthesia with 5 mcg/kg ITM (maximum 200 mcg) plus 7.5 mg isobaric bupivacaine. The primary outcome was the 24-hour cumulative intravenous morphine milligram equivalent (MME). Pain scores were recorded at rest and during activity at 0, 3, 6, 12, and 24 hours postoperatively. Patient satisfaction, recovery quality, and adverse effects were also evaluated. Results The median difference in 24 hours intravenous MME consumption between anterior subcostal QL block and ITM was 9.5 mg (95% CI 7 to 12; pConclusions Although designed as a non-inferiority trial, anterior subcostal QL block did not meet the threshold. While ITM resulted in lower opioid use, the study was not powered to establish superiority. Anterior subcostal QL block may be considered for patients at risk of ITM-related respiratory depression; however, its inconsistent cranial spread and limited visceral analgesia may explain its lower efficacy. Caution is also required in anticoagulated patients because of the deep anatomical location of the block. Trial registration number ClinicalTrials.gov: NCT06630858.

Background The effects of the erector spinae plane (ESP) block on chronic postsurgical pain (CPSP) after cardiac surgery remain unclear. This study evaluated the efficacy of bilateral ESP block in reducing the incidence and severity of CPSP after cardiac surgery. Methods This prospective, randomized, controlled, single-blind trial included 63 patients aged 18–80 years with American Society of Anesthesiologists physical status II–III, scheduled for elective cardiac surgery via median sternotomy. Participants received a bilateral ultrasound-guided ESP block or standard care without regional anesthesia. The primary outcome was the Brief Pain Inventory (BPI) score at 3 months postoperatively. Secondary outcomes included morphine consumption in the first 24 hours; Numerical Rating Scale (NRS) scores during rest/activity at 0, 3, 6, 12, and 24 hours; BPI scores at 6 months postoperatively; and Douleur Neuropathique 4 (DN4) and Hospital Anxiety and Depression Scale (HADS) scores at 3 and 6 months postoperatively. Results The BPI scores of the two groups did not differ significantly at 3 months postoperatively (median (IQR): 0(26) vs 12 (31), p=0.166). However, 24 hours postoperative morphine consumption (8 mg vs 10.5 mg, pConclusions The ESP block effectively reduced acute pain and opioid consumption; however, it had no significant effect on the incidence or severity of CPSP at 3 and 6 months.