Clinical Effectiveness of Transversus Abdominis Plane (TAP) Block versus Local Anesthesia Wound Infiltration for Postoperative Pain Relief After Laparoscopic Appendicectomy in Children: A Study Protocol for a Multicenter Double-Blind Randomized Controlled Phase III Trial

Geoffrey Bloy,1 Amelie Jurine,1 Yann Chaussy,2 Frederic Auber,2 Pierre-Gregoire Guinot,3 Belaid Bouhemad,3 Michel Francois,4 Lucie Vettoretti,1 Sebastien Pili-Floury,5 Maxime Nguyen,3 Guillaume Besch5 1CHU Besançon, Département d’Anesthésie Réanimation Chirurgicale, Besançon, F-25000, France; 2Université de Franche-Comté, CHU Besançon, SINERGIES, Service de Chirurgie Pédiatrique, Besançon, F-25000, France; 3University of Burgundy and Franche-Comté, Dijon University Hospital, INSERM LNC UMR1231, FCS Bourgogne Franche-Comté LipSTIC LabEx, Dijon, F-21000, France; 4Université de Bourgogne, CHU Dijon, Service de Chirurgie Pédiatrique, Dijon, F-21000, France; 5Université de Franche-Comté, CHU Besançon, SINERGIES, Département d’Anesthésie Réanimation Chirurgicale, Besançon, F-25000, FranceCorrespondence: Guillaume Besch, Département d’Anesthésie Réanimation Chirurgicale, CHU Besançon, 3 bvd Alexandre Fleming, Besançon, 25030, France, Tel +3381218958, Fax +3381669331, Email [email protected]: Postoperative pain relief after laparoscopic appendicectomy is a key determinant of early rehabilitation in children. Recent guidelines recommend performing either a transversus abdominis plane (TAP) block or local anesthesia (LA) wound infiltration as part of multimodal postoperative analgesia after appendectomy. To date, the clinical effectiveness of TAP block versus LA wound infiltration has never been compared. The hypothesis of this study is that the TAP block may provide a greater opioid-sparing effect after laparoscopic appendicectomy in children than LA wound infiltration.Study Design and Methods: We designed a multicenter double-blind randomized controlled phase III trial and aim to include 110 children who undergo laparoscopic appendicectomy. Children are randomized to receive either TAP block (TAP group) or LA wound infiltration (infiltration group). Multimodal analgesia is standardized in the two groups using the same protocol, which includes the stepwise prescription of paracetamol, phloroglucinol, ketoprofene, and nalbuphine according to the hetero-evaluation of pain performed by the nurses who were blinded to the treatment allocated using the validated FLACC scale. The primary outcome is the total dose of nalbuphine administered within 24 hours after surgery.Discussion: No study has specifically compared the clinical effectiveness of TAP block versus LA wound infiltration for postoperative pain relief after laparoscopic appendectomy in children. This paper describes the protocol for a randomized trial that addresses this issue. The results of this trial will be useful for editing guidelines with a higher level of evidence on this topic.Keywords: laparoscopic appendectomy, TAP block, wound infiltration, analgesia, childre

A re-evaluation of the <i>Macrothrix rosea-triserialis</i> group, with the description of two new species (Crustacea Anomopoda: Macrothricidae)

We redescribe Macrothrix rosea (females and males) based on material collected in Belgium. We also compare seven populations of Macrothrix `triserialis' from different parts of the world, including a topotypical population of M. triserialis s. str. from Sri Lanka, and males from South India (here first described), relying heavily on the structure of the trunk limbs, beside classical features of morphology. M. rosea and M. triserialis are extremely closely related: males are easily separated, but the identification of females requires micro-characters such as the relative length of the apical segment of the setae natatoriae and the adornment of the first antenna and of the longest swimming seta of the antenna. M. rosea and triserialis together constitute a sub-group of the rosea-group. Macrothrix triserialis-like animals occur in the tropical–subtropical belts of four continents. We compare populations from Asia, South America and Africa, and find differences in microcharacters of the trunk limbs, but cannot decide whether these represent random variation or sound taxonomical differences.One of the basic characters of the Macrothrix rosea-triserialis subgroup is that the setae natatoriae of the postabdomen are implanted on a prominence, the `heel'. Other characters include the fact that the Fryer' forks are adorned with one or two big teeth only, and that the scrapers of trunk limb two form a row of eight without any doublings. Possibly, scraper five, and scraper four to a lesser degree has an enlarged subapical tooth. The exopodite of trunk limb three has four plumose setae, the back and front row of the endopodite six setae and/or receptors, the exopodite of trunk limb four has two setae, and the back row of the endopodite six setae, plus one on the gnathobase. The pre-epipodite of trunk limb five consists of three lobes, the `endopodite' is small, and the `exopodite' is reduced to a single seta. The male postabdomen has a tubular ending, without true end-claws, although a rudiment of an end-claw is seen in M. triserialis.Two new species are described: M. tabrizensis and M. agsensis. A comparison, including the males of Macrothrix triserialis, M. rosea, M. smirnovi and M. tabrizensis confirms the relationship of all these taxa, but also reveals a morphological series in the shape of the postabdomen, from a complete absence of end-claws, over rudiments of a pair of end-claws, to complete endclaws. Absence of end-claws is here considered to represent an evolved character state. Macrothrix smirnovi Ciros & Elías (1987) is less closely related to the rosea-triserialis group, and is considered to form a sub-group in its own right. It shows a short `heel' on the postabdomen, but carries a supplementary seta behind scraper 4 of the endopodite of trunk limb two, and has a male with a postabdomen that closely resembles that of the female. These are primitive characters, which are also found in Wlassicsia, Bunops and Onchobunops and provide a possible phylogenetic link between Macrothrix and these three genera, although the genetic distance between them is considered to be quite large