Paravertebral anaesthesia with or without sedation versus general anaesthesia for women undergoing breast cancer surgery

Efficacy and Safety of Nerve Block for Postoperative Analgesia in Patients Undergoing Breast Cosmetic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the postoperative analgesic efficacy and safety of nerve block (NB) in patients undergoing breast surgery for cosmetic purposes.

METHODS

PubMed, Web of Science, Embase and Cochrane Libraries were searched from inception to September 2022, to identify all eligible randomized controlled trials (RCTs). Continuous data are presented as mean difference (MD) with 95% confidence intervals (CI), whereas dichotomous data are provided as odds ratios (OR) with 95% CI. This meta-analysis was performed in RevMan 5.4.

RESULTS

A total of 10 RCTs with 565 patients were meta-analyzed. Compared to the control group, the pain score of the NB group was significantly lower at postoperative 2, 3-4, 6-8, 12-16 and 24 h. Opioid consumption in the first postoperative 24 h was significantly lower in the NB group (MD = - 9.02, 95% CI - 14.29 to - 3.75, P < 0.05), I2 = 95%). In addition, the NB group showed a prolonged time to first postoperative analgesic requirement (MD = 43.15, 95% CI 4.74-81.56, P < 0.05, I2 = 96%), decreased incidence of additional postoperative analgesia (OR 0.14, 95% CI 0.07-0.28, P < 0.05, I2 = 0%) and reduced incidence of postoperative nausea or vomiting (OR 0.33; 95% CI 0.22-0.48; P < 0.05; I2 = 0%). There was no significant difference in operation duration between the two groups.

CONCLUSIONS

Nerve block is an effective and safe option for postoperative analgesia after breast cosmetic surgery.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes

BACKGROUND

Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied.

OBJECTIVE

This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery.

MATERIALS AND METHODS

All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms.

RESULTS

In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001).

CONCLUSION

Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article

Background

Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients.

Methods

An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation.

Results

A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain.

Conclusion

The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.

How should institutions help clinicians to practise greener anaesthesia: first-order and second-order responsibilities to practice sustainably

There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages.

Visualization analysis of thoracic paravertebral block in breast surgery based on bibliometrics

Background

Breast surgery is one of the most common surgeries in the world, and pain after breast surgery is very common, representing one of the key factors affecting the quality of life after surgery. With the development of clinical techniques, thoracic paravertebral block (TPVB) has gradually become the preferred regional anesthesia technique for postoperative breast analgesia.

Methods

Using Web of Science as the data source, medical articles about the application of TPVB in breast surgery published from 1900 to 2022 were retrieved and imported into CiteSpace and VOSviewer software. Using bibliometrics and knowledge mapping visualization methods, the literature was analyzed from the aspects of publication, author, institution, country, high-frequency keywords, keyword clustering, emergence words, and so on.

Results

A total of 299 articles were included. according to the yearly numbers of articles, the trend is increasing annually. The most published authors in this field are Susan M. Steele, Roy A. Greengrass, Brian M. Ilfeld, Karmakar Manoj Kumar, and Stephen M. Klein. The League of European Research Universities, University of Toronto, and Duke University are the 3 institutions with the largest number of publications, and their cooperation degree is relatively low. Articles of American origin predominated. TPVB is the major keyword associated with the application of TPVB in breast surgery, which appears most frequently and has a high research interest.

Conclusions

The trend and characteristics of TPVB application research in breast surgery were visualized, and the studies in this field are generally increasing annually in number, providing useful bibliometric analysis for researchers to further explore in this field.

Clinical Value of Total Intravenous Anesthesia with Sufentanil and Propofol in Radical Mastectomy

Objective

To investigate the clinical value of sufentanil combined with propofol for total intravenous anesthesia (TIVA) in radical mastectomy.

Methods

The data of 120 patients undergoing radical mastectomy of breast cancer in our hospital from February 2020 to February 2021 were retrospectively analyzed, and they were randomly assigned to the experimental group (EXG) (n = 60) and the control group (COG) (n = 60). The anesthesia maintenance scheme was 0.01–0.03 μg/(kg·min) of sufentanil + 80–100 μg/(kg·min) of propofol in EXG and 3 μg/(kg·h) of fentanyl + 80–100 μg/(kg·min) of propofol in COG. The hemodynamic indices, stress indexes, postoperative pain scores, and incidence of adverse reactions were compared between EXG and COG.

Results

The heart rates (HR) and mean arterial pressure (MAP) after tracheal intubation (T₂) and at separation of deep tissues (T₃), tracheal extubation (T₄), and the end of surgery (T₅) were markedly lower in EXG than in COG (P < 0.001). The stress indexes and postoperative pain scores at 1 h (T₆), 6 h (T₇), and 12 h (T₈) after surgery were lower in EXG than in COG (P < 0.001). The incidence of dizziness, headache, pruritus, and emergence agitation in EXG was lower compared with that in COG (P < 0.05).

Conclusion

Sufentanil combined with propofol for TIVA can stabilize intraoperative hemodynamic indices of patients undergoing radical mastectomy, alleviate perioperative stress response, and reduce pain perception. Therefore, this anesthesia method is safe and merits clinical promotion.

Antitumorigenic Effect of Tramadol and Synergistic Effect With Doxorubicin in Human Breast Cancer Cells

Background

Breast cancer in women is one of the leading causes of cancer mortality worldwide, and curative therapy is the main focus of clinical treatment. Anesthetic-analgesic techniques might alter stress responses and immunity and thereby influence outcomes in cancer patients. This study investigated the effect of tramadol on breast cancer progression and metastasis.

Methods

The effects of tramadol on two different subtypes of human breast adenocarcinoma cell lines, MDA-MB-231 and MCF-7, were studied with regard to cell growth, migration, colony formation and invasion and normoxic or hypoxic microenvironment for the expression of hypoxia-inducible factor-1α, reactive oxygen species, epithelial-mesenchymal transition related and cyclin-related proteins. The co-administration of tramadol and doxorubicin was studied to determine whether the effective doxorubicin dose might be reduced in combination with tramadol.

Results

The results showed that tramadol inhibited cell growth at concentrations more than 0.5 and more than 1.0 mg/mL in MDA-MB-231 and MCF-7 cells, respectively. Additionally, cell migration, colony formation and invasion were inhibited in a dose-dependent manner by tramadol in both cell lines. The combination of tramadol and doxorubicin induced synergistic effects in MDA-MD-231 cells and, with specific dosage combinations in MCF-7 cells.

Conclusions

Tramadol may regulate epithelial-mesenchymal transition and possess cytotoxic effects in breast cancer cells. Tramadol inhibits the progression of breast cancer cells and might be a candidate for combination therapy, especially for triple-negative breast cancer, and is a promising treatment strategy for breast cancer.

Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

Serratus anterior plane block (SAPB) provides effective thoracic analgesia. This systematic review and meta-analysis was conducted to assess the safety and efficacy of SAPB for postoperative analgesia after breast surgery.

Methods

A systematic literature search was performed using Embase, PubMed, Web of Science, and the Cochrane Library for eligible randomised controlled trials. The primary outcomes involved the administration of intraoperative and postoperative opioids. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for rating the quality of evidence for making recommendations.

Results

Overall, 13 studies comprising 826 patients met the inclusion criteria (412 in the SAPB group and 414 in the control group). Patients treated with SAPB exhibited a significantly lower postoperative opioid consumption (mean difference, −38.51 mg of oral morphine equivalent; 95% confidence interval (CI), −60.97 to −16.05; P < 0.01; I² = 100%), whereas no difference was observed in the intraoperative opioid consumption (mean difference, −9.85 mg of oral morphine equivalent; 95% CI, −19.52 to −0.18; P=0.05; I² = 94%). In addition, SAPB significantly decreased the occurrence of postoperative nausea and vomiting (risk ratio, 0.32; 95% CI, 0.19–0.55; P < 0.05;I² = 38%) and reduced pain scores during the postoperative period (1 h: standardised mean difference (SMD), −1.23; 95% CI, −2.00 to −0.45; I² = 92%; 2 h: SMD, −0.71; 95% CI, −1.00 to −0.41; I² = 48%; 4 h: SMD, −1.52; 95% CI, −2.77 to −0.27; I² = 95%; 6 h: SMD, −0.80; 95% CI, −1.51 to −0.08; I² = 81%; 8 h: SMD, −1.12; 95% CI, −1.98 to −0.27; I² = 92%; 12 h: SMD, −0.78; 95% CI, −1.21 to −0.35; I² = 83%; and 24 h: SMD, −0.71; 95% CI, −1.20 to −0.23; I² = 87%; P < 0.05 for all).

Conclusion

SAPB was safe and effective after breast surgery to relieve postsurgical pain. However, additional well-developed trials are required to validate these findings.