{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T17:04:03Z","timestamp":1789578243744,"version":"build-2803163510"},"reference-count":45,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Fascial plane blocks reduce opioid consumption after bariatric surgery, but the optimal timing of administration remains unclear. We compared pre-incision versus end-of-surgery block timing. Methods: This was a retrospective observational cohort study of consecutive patients undergoing laparoscopic sleeve gastrectomy at a single centre. All patients received a left external oblique intercostal block plus a bilateral rectus sheath block with 0.25% bupivacaine, performed by the same two experienced anaesthesiologists either before incision or at the end of surgery. Ward staff who routinely recorded postoperative pain scores did not have access to the anaesthesia record and were therefore unaware of block timing. The primary outcome was the numeric rating scale (NRS) pain score at post-anaesthesia care unit (PACU) admission. Repeated pain scores were analysed using generalized estimating equations (GEE) with an exchangeable correlation structure and robust standard errors, adjusted for BMI, ASA status and anaesthesia duration, and group\u2009 \u00d7 \u2009time interaction was tested. Secondary outcomes included 24 h intravenous morphine milligram equivalents (IV-MME) and the 24 h Quality of Recovery-15 (QoR-15) score, analysed with adjustment for baseline. Results: Fifty-four patients were analysed (pre-incision n = 28, post-surgery n = 26). Median NRS at PACU admission was lower in the pre-incision group (4.5 [IQR 2.0\u20138.0] vs. 7.0 [IQR 7.0\u20138.0]; p = 0.008). In the adjusted GEE model, pre-incision timing was associated with a 1.53-point lower NRS across the postoperative period (95% CI \u22122.15 to \u22120.91; p &lt; 0.001). The between-group difference attenuated over time, from \u22122.42 points (95% CI \u22123.72 to \u22121.12) at PACU admission to \u22120.81 points (95% CI \u22121.30 to \u22120.33) at 24 h, although the group \u00d7 time interaction did not reach significance (p = 0.075). PACU rescue fentanyl (median 62 [IQR 25\u2013106] vs. 150 [IQR 100\u2013194] \u00b5g; p &lt; 0.001) and 24 h PCA tramadol (median 120 [IQR 100\u2013150] vs. 172 [IQR 141\u2013199] mg; p &lt; 0.001) were both lower in the pre-incision group; mean consumption was 44% and 26% lower, respectively, corresponding to a 35% lower mean total IV-MME. No statistically significant difference in quality of recovery was detected, and the estimate was imprecise; the baseline-adjusted 24 h QoR-15 difference was 5.3 points (95% CI \u22127.0 to 17.6; p = 0.391). An exploratory subdomain analysis suggested better physical comfort with pre-incision timing, but this did not survive correction for multiple comparisons. Conclusions: In this retrospective cohort, pre-incision administration of fascial plane blocks was associated with lower early postoperative pain and lower recorded opioid consumption than end-of-surgery administration, with no statistically significant difference in overall quality of recovery, although that estimate was imprecise. Because block timing was determined by operating-room logistics rather than by randomisation, and intraoperative opioid exposure could not be quantified, these associations require confirmation in a prospective randomised trial before they can guide practice.<\/jats:p>","DOI":"10.3390\/jcm15187204","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T16:07:29Z","timestamp":1789574849000},"page":"7204","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Timing of Fascial Plane Blocks in Bariatric Surgery: Pre-Incision Administration Is Associated with Lower Early Pain and Opioid Consumption"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5058-7039","authenticated-orcid":false,"given":"Alper Tunga","family":"Do\u011fan","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Pain Clinic, VKV American Hospital, 34365 Istanbul, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1506-6435","authenticated-orcid":false,"given":"Sami Kaan","family":"Co\u015farcan","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Clinic, VKV American Hospital, 34365 Istanbul, Turkey"},{"name":"Department of Anesthesiology and Reanimation, Ko\u00e7 University School of Medicine, 34010 Istanbul, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0623-5911","authenticated-orcid":false,"given":"Yunus","family":"Yavuz","sequence":"additional","affiliation":[{"name":"Department of General Surgery\u2014Bariatric and Metabolic Surgery Unit, VKV American Hospital, 34365 Istanbul, Turkey"},{"name":"Department of General Surgery, Ko\u00e7 University School of Medicine, 34010 Istanbul, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"\u00d6m\u00fcr","family":"Er\u00e7elen","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Clinic, VKV American Hospital, 34365 Istanbul, Turkey"},{"name":"Department of Anesthesiology and Reanimation, Ko\u00e7 University School of Medicine, 34010 Istanbul, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2180","DOI":"10.1007\/s11695-019-03831-6","article-title":"Comparative efficacy of bariatric surgery in the treatment of morbid obesity and diabetes mellitus: A systematic review and network meta-analysis","volume":"29","author":"Park","year":"2019","journal-title":"Obes. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1724","DOI":"10.1001\/jama.292.14.1724","article-title":"Bariatric surgery: A systematic review and meta-analysis","volume":"292","author":"Buchwald","year":"2004","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1007\/s11695-014-1185-2","article-title":"Postoperative analgesia in morbid obesity","volume":"24","author":"Alvarez","year":"2014","journal-title":"Obes. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"885","DOI":"10.1093\/bja\/aex341","article-title":"Death or near-death in patients with obstructive sleep apnoea: A compendium of case reports of critical complications","volume":"119","author":"Subramani","year":"2017","journal-title":"Br. J. Anaesth."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1213\/ANE.0000000000004194","article-title":"American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on perioperative opioid minimization in opioid-na\u00efve patients","volume":"129","author":"Wu","year":"2019","journal-title":"Anesth. Analg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1007\/s00464-019-06911-x","article-title":"Canadian consensus statement: Enhanced recovery after surgery in bariatric surgery","volume":"34","author":"Dang","year":"2020","journal-title":"Surg. Endosc."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"2133","DOI":"10.1016\/j.soard.2020.03.010","article-title":"Multimodal analgesia in bariatric surgery: Not just an intravenous approach","volume":"16","author":"Carron","year":"2020","journal-title":"Surg. Obes. Relat. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Ibrahim, M., Elnabtity, A.M., Hegab, A., Alnujaidi, O.A., and El Sanea, O. (2022). Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: A randomized controlled trial. BMC Anesthesiol., 22.","DOI":"10.1186\/s12871-021-01561-w"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1097\/AAP.0000000000000545","article-title":"Essentials of our current understanding: Abdominal wall blocks","volume":"42","author":"Chin","year":"2017","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1166","DOI":"10.1097\/ALN.0000000000002842","article-title":"Transversus abdominis plane block: A narrative review","volume":"131","author":"Tran","year":"2019","journal-title":"Anesthesiology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2436","DOI":"10.1093\/pm\/pnab296","article-title":"The external oblique intercostal block: Anatomic evaluation and case series","volume":"22","author":"Elsharkawy","year":"2021","journal-title":"Pain Med."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Saleem, S.Z., Akhtar, S.M.M., Fareed, A., Shaik, A.A., and Asghar, M.S. (2025). Redefining pain management: Investigating the efficacy and safety of erector spinae plane block and oblique subcostal transversus abdominis plane block in laparoscopic cholecystectomy\u2014A meta-analysis of randomized controlled trials. BMC Anesthesiol., 25.","DOI":"10.1186\/s12871-025-03059-1"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Ciftci, B., Alver, S., G\u00f6lboyu, B.E., Haksal, M.C., Tulgar, S., De Cassai, A., and Alici, H.A. (2025). A comparison of two fascial plane blocks for abdominal analgesia in laparoscopic cholecystectomy surgery (M-TAPA vs. external oblique intercostal plane block): A prospective randomized study. J. Clin. Med., 14.","DOI":"10.3390\/jcm14093050"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2921","DOI":"10.1007\/s11695-022-06184-9","article-title":"Can Postoperative Pain Be Prevented in Bariatric Surgery? Efficacy and Usability of Fascial Plane Blocks: A Retrospective Clinical Study","volume":"32","author":"Yavuz","year":"2022","journal-title":"Obes. Surg."},{"key":"ref_15","first-page":"1024","article-title":"The TAP block in obese patients: Pros and cons","volume":"85","author":"Albrecht","year":"2019","journal-title":"Minerva Anestesiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1007\/s11695-024-07174-9","article-title":"Ultrasound-guided external oblique intercostal plane block for postoperative analgesia in laparoscopic sleeve gastrectomy: A prospective, randomized, controlled, patient and observer-blinded study","volume":"34","author":"Kavakli","year":"2024","journal-title":"Obes. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1826","DOI":"10.1007\/s11695-024-07219-z","article-title":"External oblique intercostal plane block versus port-site infiltration for laparoscopic sleeve gastrectomy: A randomized controlled study","volume":"34","author":"Doymus","year":"2024","journal-title":"Obes. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"3726","DOI":"10.1007\/s11695-024-07454-4","article-title":"Bilateral Ultrasound-Guided External Oblique Intercostal Block Vs. Modified Thoracoabdominal Nerve Block Through Perichondrial Approach for Postoperative Analgesia in Patients Undergoing Laparoscopic Sleeve Gastrectomy Surgery: A Randomized Controlled Study","volume":"34","author":"Turunc","year":"2024","journal-title":"Obes. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"159","DOI":"10.4097\/kja.24569","article-title":"Analgesic efficacy of the external oblique intercostal fascial plane block on postoperative acute pain in laparoscopic sleeve gastrectomy: A randomized controlled trial","volume":"78","author":"Ozel","year":"2025","journal-title":"Korean J. Anesthesiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"41","DOI":"10.4103\/ija.ija_1080_25","article-title":"Impact of external oblique intercostal plane block on postoperative pain and opioid consumption after laparoscopic sleeve gastrectomy: A systematic review and meta-analysis","volume":"70","author":"Arora","year":"2026","journal-title":"Indian J. Anaesth."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Xiao, H., Du, Y., Li, G., Deng, Y., and Ren, Y. (2025). Nerve block techniques utilized in post-bariatric surgery: A narrative review. BMC Surg., 25.","DOI":"10.1186\/s12893-025-02801-3"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1332","DOI":"10.1097\/ALN.0b013e318289b84b","article-title":"Development and psychometric evaluation of a postoperative quality of recovery score: The QoR-15","volume":"118","author":"Stark","year":"2013","journal-title":"Anesthesiology"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1093\/oxfordjournals.bja.a013366","article-title":"Validity and reliability of a postoperative quality of recovery score: The QoR-40","volume":"84","author":"Myles","year":"2000","journal-title":"Br. J. Anaesth."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1016\/j.bja.2017.11.013","article-title":"Systematic review of the QoR-15 score, a patient-reported outcome measure measuring quality of recovery after surgery and anaesthesia","volume":"120","author":"Kleif","year":"2018","journal-title":"Br. J. Anaesth."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.1016\/j.bja.2022.03.009","article-title":"Measurement of quality of recovery after surgery using the 15-item quality of recovery scale: A systematic review and meta-analysis","volume":"128","author":"Myles","year":"2022","journal-title":"Br. J. Anaesth."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"934","DOI":"10.1097\/ALN.0000000000003977","article-title":"An updated minimal clinically important difference for the QoR-15 scale","volume":"135","author":"Myles","year":"2021","journal-title":"Anesthesiology"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1097\/ACO.0000000000000612","article-title":"Measuring quality of recovery in perioperative clinical trials","volume":"31","author":"Myles","year":"2018","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1345\/aph.1H421","article-title":"Opioid conversions in acute care","volume":"41","author":"Patanwala","year":"2007","journal-title":"Ann. Pharmacother."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"443","DOI":"10.5152\/TJAR.2022.21417","article-title":"Translation and validation of the Turkish version of the quality of postoperative recovery score QoR-15: A multi-centred cohort study","volume":"50","author":"Selvi","year":"2022","journal-title":"Turk. J. Anaesthesiol. Reanim."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e37867","DOI":"10.1097\/MD.0000000000037867","article-title":"The validity and reliability of the Turkish version of the quality of recovery-15 (QoR-15) questionnaire","volume":"103","author":"Aslanlar","year":"2024","journal-title":"Medicine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1097\/ALN.0000000000001158","article-title":"Minimal clinically important difference for three quality of recovery scales","volume":"125","author":"Myles","year":"2016","journal-title":"Anesthesiology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/S0304-3959(03)00176-3","article-title":"What decline in pain intensity is meaningful to patients with acute pain?","volume":"105","author":"Cepeda","year":"2003","journal-title":"Pain"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Jeong, H.W., Kim, C.S., Choi, K.T., Jeong, S.M., Kim, D.H., and Lee, J.H. (2019). Preoperative versus postoperative rectus sheath block for acute postoperative pain relief after laparoscopic cholecystectomy: A randomized controlled study. J. Clin. Med., 8.","DOI":"10.3390\/jcm8071018"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Acar, M.S., Pehlivan, V.F., Pehlivan, B., and Duran, E. (2025). Timing matters: A randomized controlled trial comparing preoperative and postoperative erector spinae plane block for analgesia in laparoscopic cholecystectomy. Medicina, 61.","DOI":"10.3390\/medicina61101806"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Fernandez Martin, M.T., Mariano, E.R., Valdes-Vilches, L.F., Lopez Alvarez, S., and Elkassabany, N. (2025). Analgesia for upper abdominal surgery, a scoping review of the current fascial plane block techniques. J. Clin. Med., 14.","DOI":"10.3390\/jcm14248632"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1353","DOI":"10.1213\/ANE.0000000000002779","article-title":"Efficacy of ultrasound-guided serratus plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery","volume":"126","author":"Kim","year":"2018","journal-title":"Anesth. Analg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1480","DOI":"10.1213\/ANE.0b013e3182334d8b","article-title":"The effect of neuraxial versus general anesthesia on postoperative quality of recovery and analgesia after abdominal hysterectomy","volume":"113","author":"Gonclaves","year":"2011","journal-title":"Anesth. Analg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1093\/bja\/aev413","article-title":"Measuring quality of recovery-15 after day case surgery","volume":"116","author":"Chazapis","year":"2016","journal-title":"Br. J. Anaesth."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1138","DOI":"10.1097\/00000542-200010000-00040","article-title":"Preemptive analgesia","volume":"93","author":"Kissin","year":"2000","journal-title":"Anesthesiology"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1213\/00000539-199377020-00026","article-title":"Preemptive analgesia\u2014Treating postoperative pain by preventing the establishment of central sensitization","volume":"77","author":"Woolf","year":"1993","journal-title":"Anesth. Analg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1016\/j.jss.2024.04.050","article-title":"Association of sex differences on weight loss and complications following bariatric surgery","volume":"299","author":"Hider","year":"2024","journal-title":"J. Surg. Res."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1093\/bja\/aex005","article-title":"Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block","volume":"118","author":"Rahiri","year":"2017","journal-title":"Br. J. Anaesth."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1423","DOI":"10.1007\/s12630-025-03034-x","article-title":"Local anesthetic dosing for fascial plane blocks to avoid systemic toxicity: A narrative review","volume":"72","author":"Bailey","year":"2025","journal-title":"Can. J. Anaesth."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1136\/rapm-2020-101986","article-title":"American Society of Regional Anesthesia and Pain Medicine local anesthetic systemic toxicity checklist: 2020 version","volume":"46","author":"Neal","year":"2021","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"888","DOI":"10.1016\/j.soard.2022.03.019","article-title":"Nonsteroid anti-inflammatory drugs and the risk of peptic ulcers after gastric bypass and sleeve gastrectomy","volume":"18","author":"Skogar","year":"2022","journal-title":"Surg. Obes. Relat. Dis."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7204\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T16:30:36Z","timestamp":1789576236000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/18\/7204"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,16]]},"references-count":45,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15187204"],"URL":"https:\/\/doi.org\/10.3390\/jcm15187204","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,16]]}}}