Rhomboid intercostal block with subserratus plane block in bariatric surgery: a three-arm prospective randomized comparative study

Background and objectivesBariatric surgery is an effective intervention for managing obesity, yet postoperative pain management remains a significant challenge. Standard analgesic techniques such as patient-controlled analgesia (PCA) and continuous epidural analgesia (CEA) are effective but associated with considerable side effects, including nausea, hypotension, and respiratory depression. This study aimed to evaluate the efficacy and safety of the rhomboid intercostal block combined with subserratus plane block (RISS) compared to PCA and CEA for postoperative analgesia in bariatric surgery.MethodsA prospective randomized comparative study was conducted, enrolling 144 patients undergoing elective bariatric surgery. Participants were randomized into three groups: PCA, CEA, and RISS. Pain scores (numerical rating scale, NRS) at rest and during movement, opioid consumption, and side effects were assessed at 4, 8, 12, and 24 hours postoperatively. Statistical analyses included one-way ANOVA and repeated-measures ANOVA to evaluate the efficacy and non-inferiority of RISS compared to PCA and CEA.ResultsIntraoperatively, the ephedrine dosage (mg) in the PCA and RISS groups was significantly lower than that in the CEA group (P = 0.0003). RISS provided comparable analgesic efficacy to CEA. At 12 hours postoperatively, rest pain scores (NRS) were 3.7 ± 0.4 in the PCA group, 2.7 ± 0.3 in the CEA group, and 2.3 ± 0.3 in the RISS group (P &lt; 0.0001). Morphine-equivalent consumption at 24 hours was significantly lower in the RISS (7.7 ± 2.2 mg) and CEA (7.6 ± 2.1 mg) groups compared to PCA (15.7 ± 3.2 mg, P &lt; 0.0001). RISS was associated with a significantly lower incidence of postoperative nausea and vomiting (18.42%) compared to PCA (47.37%, P = 0.0195). Additionally, RISS improved sleep quality on the first postoperative night (Likert score: RISS 3.6 ± 0.3 vs. PCA 2.9 ± 0.2, P = 0.0030) and showed no severe complications.ConclusionRISS is a safe and effective postoperative analgesic technique for bariatric surgery, achieving pain relief comparable to CEA but with fewer side effects, and demonstrating superior outcomes compared to PCA. This study supports the adoption of RISS in clinical practice to enhance postoperative pain management and patient recovery in bariatric surgery.<br>

背景与目的
减重代谢手术是管理肥胖的有效干预手段，但术后疼痛管理仍是一项重大挑战。患者自控镇痛（patient-controlled analgesia, PCA）、持续硬膜外镇痛（continuous epidural analgesia, CEA）等经典镇痛技术虽疗效确切，但易引发诸多不良反应，包括恶心、低血压与呼吸抑制。本研究旨在对比评估菱形肌肋间阻滞联合肋下肌平面阻滞（rhomboid intercostal block combined with subserratus plane block, RISS）与PCA、CEA用于减重代谢手术术后镇痛的有效性与安全性。

方法
本研究为前瞻性随机对照研究，纳入144例行择期减重代谢手术的患者，按随机原则分为PCA组、CEA组与RISS组。分别于术后4、8、12及24小时评估患者静息及活动时的疼痛评分（numerical rating scale, NRS）、阿片类药物使用量及不良反应发生情况。统计分析采用单因素方差分析及重复测量方差分析，以评估RISS相较于PCA与CEA的镇痛有效性及非劣效性。

结果
术中PCA组与RISS组的麻黄碱使用剂量（mg）显著低于CEA组（P=0.0003）。RISS的镇痛疗效与CEA相当。术后12小时，PCA组静息疼痛评分（NRS）为3.7±0.4，CEA组为2.7±0.3，RISS组为2.3±0.3（P<0.0001）。术后24小时的吗啡等效用药量，RISS组（7.7±2.2mg）与CEA组（7.6±2.1mg）均显著低于PCA组（15.7±3.2mg，P<0.0001）。与PCA组（47.37%）相比，RISS组术后恶心呕吐发生率显著更低（18.42%，P=0.0195）。此外，RISS组术后第一晚的睡眠质量更优（李克特评分：RISS组3.6±0.3 vs PCA组2.9±0.2，P=0.0030），且未出现严重并发症。

结论
对于减重代谢手术患者，RISS是一种安全有效的术后镇痛技术：其镇痛效果与CEA相当，但不良反应更少，且疗效优于PCA。本研究支持在临床实践中采用RISS，以优化减重代谢手术的术后疼痛管理并促进患者术后康复。