Comparative Effectiveness of Fascial Plane Blocks for Postoperative Analgesia in Laparoscopic Sleeve Gastrectomy: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials.

INTRODUCTION

Globally, laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric surgery. Multiple fascial plane blocks are used for postoperative analgesia, but their comparative efficacy remains unclear.

METHODS

A systematic search through January 2026 identified controlled trials comparing fascial plane blocks-including transversus abdominis plane block (TAP), erector spinae plane block (ESPB), quadratus lumborum (QL), external oblique intercostal (EOI), modified thoracoabdominal nerve block via perichondrial approach (M-TAPA), paravertebral block (PVB), and rectus sheath (RS) blocks-against each other, placebo, systemic analgesia (SA), or port-site infiltration (PSI) in LSG. The primary outcome was 24-hour opioid consumption (morphine milligram equivalents, MME). Secondary outcomes included pain scores at 2 to 24 hours, postoperative nausea and vomiting (PONV), and complications. A frequentist network meta-analysis was conducted. Treatment rankings were determined using surface under the cumulative ranking curve (SUCRA) values, and the certainty of evidence was appraised by the Grading of Recommendation Assessment, Development, and Evaluation (GRADE).

RESULTS

Twenty-three randomized controlled trials (RCTs) comprising 2,005 patients were included. The EOI block achieved the greatest opioid-sparing effect versus SA (mean difference [MD] -19.66 MME; [SUCRA] 83%). At 24 hours, only ESPB significantly reduced pain intensity (MD -0.44). The QL block significantly decreased PONV incidence compared to placebo (odds ratio [OR] 0.31). No major block-related adverse events were reported. Overall, the quality of evidence ranged from moderate to low.

CONCLUSIONS

In adults undergoing LSG, ultrasound-guided fascial plane blocks are effective and safe for postoperative analgesia. The EOI block was probabilistically ranked highest for reducing 24-hour opioid consumption (SUCRA 83%), though CIs overlapped with other blocks. The ESPB provided a small but statistically significant reduction in pain at 24 hours (MD -0.44), and the QL was associated with the lowest incidence of PONV (OR 0.31). However, the overall certainty of evidence ranged from moderate to low, with interventions supported by limited data from only one or two trials. SUCRA rankings represent probabilistic hierarchies and should not be interpreted as definitive evidence of superiority. Consequently, technique selection should be guided by specific analgesic goals, local expertise, and individual patient factors.