Infiltration de ropivacaïne en chirurgie carcinologique du sein : effet sur la douleur postopératoire aiguë et chronique

The Use of Wound Infiltration for Postoperative Pain Management after Breast Cancer Surgery: A Randomized Clinical Study

(1) Background: The present study aims to evaluate the reduction of postoperative pain in breast surgery using a series of local analgesics, which were infiltrated into the wound; (2) Methods: Envelopes containing allocation were prepared prior to the study. The patients involved were randomly assigned to the groups of local anesthesia infiltration (Group A) or normal pain management with intravenous analgesics (Group B). The random allocation sequence was generated using computer-generated random numbers. The normally distributed continuous data were expressed as the means (SD) and were assessed using the analysis of variance (ANOVA), independent-sample t-test, or paired t-test; (3) Results: The development of the postoperative pain stages was recorded using the VAS score. Therefore, for Group A, the following results were obtained: the VAS at 6 h postoperatively showed an average value of 0.63 and a maximum value of 3. The results for Group B were the following: the VAS score at 6 h postoperatively showed an average value of 4.92, a maximum of 8, and a minimum of 2; (4) Conclusions: We can confirm that there are favorable statistical indicators regarding the postoperative pain management process during the first 24-38 h after a surgical intervention for breast cancer using local infiltration of anesthetics.

The Role of Regional Anesthesia in the Development of Chronic Pain: a Review of Literature

Purpose of Review

The acute management of pain using regional anesthesia techniques may prevent the development of persistent postsurgical pain (PPP), ultimately improving patient outcomes and enhancing overall quality of life in postsurgical patients. The purpose of this review is to describe the current literature regarding the role of regional anesthesia techniques in the perioperative setting to address and prevent PPP.

Recent Findings

Data was collected and analyzed using results from randomized controlled studies stratified into categories based on different surgical subspecialties. Conclusions were drawn from each surgical category regarding the role of regional anesthesia and/or local analgesia in acute and chronic pain management on the long-term results seen in the studies analyzed.

Summary

Preoperative consultations and optimized perioperative analgesia using regional anesthesia and local analgesia play a fundamental role preventing and treating postoperative pain after many types of surgery by managing pain in the acute setting to mitigate the future development of PPP. Additional studies in different surgical subspecialties are needed to confirm the role regional anesthesia plays in chronic postsurgical pain (CPSP) prevention.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.

METHODS

In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.

RESULTS

Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.

CONCLUSION

Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.

STUDY REGISTRATION

PROSPERO (CRD42020198244); registered 19 October 2020.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Regional anesthetics versus analgesia for stopping the persistent postsurgical pain: A meta-analysis

INTRODUCTION

Regional anesthesia might moderate the risk of persistent postsurgical pain, but its effect compared to systemic analgesia is still conflicting. This meta-analysis study was performed to assess the relationship between the efficiency of regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery.

METHODS

Through a systematic literature search up to August 2020, 31 studies included 2975 subjects who underwent surgery at baseline and reported a total of 1471 subjects using regional anesthesia and 1319 subjects using conventional anesthesia were found recording relationships between efficiency of regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery. Odds ratio (OR) with 95% confidence intervals (CIs) was calculated between regional anesthesia versus systemic analgesia in reducing pain persisting longer than 3 months after surgery using the dichotomous methods with a random or fixed-effect model.

RESULTS

Number of subjects reporting persistent pain 3 months postsurgery was significantly lower in regional anesthesia compared to systemic analgesia in thoracotomy (OR, 0.44; 95% CI, 0.29-0.65, P < .001); breast surgery (OR, 0.46; 95% CI, 0.29-0.72, P < .001); and cesarean section (OR, 0.44; 95% CI, 0.27-0.72, P < .001).

CONCLUSIONS

Regional anesthesia might have an independent relationship with lower pain persisting longer than 3 months after thoracotomy, breast surgery, and cesarean section. Further studies are required to validate these findings.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

STUDY OBJECTIVE

Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery.

DESIGN

Systematic review and network meta-analysis.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients scheduled for breast surgery under general anesthesia.

INTERVENTIONS

Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced.

MEASUREMENTS

Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status.

MAIN RESULTS

In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques.

CONCLUSIONS

In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Ropivacaine infiltration analgesia of the drainage exit site enhanced analgesic effects after breast Cancer surgery: a randomized controlled trial

BACKGROUND

Postoperative pain after breast cancer surgery remains a major challenge in patient care. Local infiltration analgesia is a standard analgesic technique used for pain relief after surgery. Its application in patients who underwent mastectomy requires more clear elucidation. This study aimed to investigate the effect of ropivacaine infiltration of drainage exit site in ameliorating the postoperative pain after mastectomy.

METHODS

A prospective randomized controlled study was conducted in 74 patients who were scheduled for unilateral mastectomy by standardized general anesthesia. Both intervention group and control group were given infiltration of the two entry points of drainage catheters with 10 ml 0.5% ropivacaine (Group A) (n = 37) or 10 ml normal saline (Group B) (n = 37). Pain scores were recorded in post-anesthesia care unit (PACU), at 6 h, 12 h, 24 h and 36 h after operation by using a visual analogue scale (VAS). Postoperative nausea and vomiting (PONV) incidence, postoperative analgesic and antiemetic requirements, the incidence of chronic pain, as well as the quality of recovery were recorded.

RESULTS

The patients in Group A showed a significant reduction in postoperative pain in PACU (p < 0.0005), at 6 h (p < 0.0005), 12 h (p < 0.0005), and 24 h after surgery (p < 0.05) when compared to those in Group B. There were more postoperative analgesic requirements in Group B (p < 0.05). With regard to the quality of recovery, Group A was shown to be much superior over Group B (p < 0.05).

CONCLUSIONS

Ropivacaine infiltration of the two drainage exit sites decreased the degree of postoperative acute pain after mastectomy, and this approach improved patients' quality of recovery.

TRIAL REGISTRATION

retrospectively registered in Chictr.org.cn registry system on 24 February 2020 ( ChiCTR2000030139 ).

Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses

BACKGROUND AND OBJECTIVE

The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.

DATABASES AND DATA TREATMENT

We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.

RESULTS

Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.

CONCLUSIONS

Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed.

SIGNIFICANCE

This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.

Continuous Wound Infiltration With Ropivacaine After Mastectomy: A Randomized Controlled Trial

BACKGROUND

To evaluate the efficacy of continuous wound infiltration with ropivacaine to reduce acute postoperative pain in patients undergoing mastectomy for carcinoma of the breast.

MATERIALS AND METHODS

A randomized, double-blind, placebo-controlled trial was conducted. One hundred fifty patients were randomly assigned to receive continuous ropivacaine (0.2%) (group A, n = 74) or saline solution (0.9%) (group B, n = 76) at 10 mL/h for 48 h through a multilumen catheter placed during the surgical procedure. Postoperative morphine consumption and visual analog scale (VAS) pain scores were recorded. A quality of life score (Quality of life questionnaire Core 30) and a VAS score were obtained at 1, 3, and 6 mo after surgery.

RESULTS

The difference in mean morphine consumption between the two groups was close to significance during the first 48 h postsurgery (P = 0.056; 10.8 ± 16.5 versus 4.8 ± 10.4 mg). At day 1, patients in the ropivacaine-infusion group had lower morphine consumption than the control group (P = 0.0026). The link between local ropivacaine infiltration and a decrease in mean postoperative VAS scores reached significance for the first 24 h postsurgery (P = 0.039). No significant difference was found between the two arms for VAS pain scores (P = 0.36) or for quality of life (overall QLQ-C30 score, P = 0.09) at 1, 3, or 6 mo.

CONCLUSIONS

Continuous wound infiltration with ropivacaine is efficacious in reducing postoperative pain. Quality of life and chronic pain at 1, 3, and 6 mo were not improved by ropivacaine wound infiltration.

Local anesthetics and regional anesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children: A Cochrane systematic review and meta-analysis update

BACKGROUND

Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017.

METHODS

We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias.

RESULTS

40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence).

CONCLUSIONS

Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

BACKGROUND

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

SELECTION CRITERIA

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

MAIN RESULTS

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

AUTHORS' CONCLUSIONS

We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.

Intraoperative instillation of ropivacaine during the placement of sub-muscular cosmetic breast implants: Is there a clinical benefit?

INTRODUCTION

The sub-muscular placement of cosmetic breast implants leads to substantial pain due to the muscular distention. The aim of this study was to assess the efficiency of intraoperative ropivacaine instillation to reduce postoperative pain the day after surgery.

MATERIAL AND METHODS

We conducted a prospective, controlled, single-blinded study comparing the intraoperative instillation of 7.5mg of ropivacaine through Redon drains with the standard procedure in 72 patients undergoing sub-muscular cosmetic breast augmentation for the first time.

RESULTS

Pain at the awakening on postoperative day 1 was 4.8 on a simple numeric pain scale in the treatment group and 5.1 in the control group (P>0.05). On postoperative day 3, pain at awakening was 3.7 in both groups (P>0.05), and on postoperative day 5, pain was 2.8 in the treatment group and 2.7 in the control group (P>0.05).

CONCLUSION

Local instillation of ropivacaine in the implant pocket during surgery did not decrease postoperative pain on day 1, day 3 and day 5. From now on, we are able to tell to patients that the postoperative pain after sub-muscular cosmetic breast implants surgery is about 5/10 on postoperative day 1, 4/10 at day 3 and 3/10 at day 5.

LEVEL OF EVIDENCE

Level II.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

Effect of wound infiltration with ropivacaine or bupivacaine analgesia in breast cancer surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Although not completely painless, breast-conserving surgery is considerably less painful than modified radical mastectomy. Local anesthetics are speculated to reduce postoperative pain when placed at the surgical site. Thus, we conducted a systematic review of randomized controlled trials to evaluate the efficacy of bupivacaine or ropivacaine analgesia for pain relief in breast cancer surgery.

METHODS

PubMed, Embase, the Cochrane Library, Scopus, and the ClinicalTrials.gov registry were searched for studies published up to July 2015. Individual effect sizes were standardized, and a meta-analysis was performed to calculate a pooled effect size by using random effects models. Pain was assessed using a visual analog scale at 1, 2, 12, and 24 h postoperatively. The secondary outcomes included complications and analgesic consumption.

RESULTS

We reviewed 13 trials with 1150 patients. We found no difference in postoperative pain reduction at 1, 12, and 24 h after breast cancer surgery between the experimental and control groups. The severity of pain was significantly reduced in the experimental group (weighted mean difference -0.19; 95% confidence interval: -0.39-0.00) at 2 h postoperatively. Moreover, postoperative analgesic consumption did not differ significantly between the groups. No major drug-related complication was observed in any study.

CONCLUSION

Administration of the local anesthetics bupivacaine or ropivacaine during breast cancer surgery decreased pain significantly at only 2 h but did not reduce pain at 12, and 24 h postoperatively.

A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy

Background

Perioperative neuropathic pain is under-recognized and often undertreated. Chronic pain may develop after any routine surgery, but it can have a far greater incidence after amputation, thoracotomy or mastectomy. The peak noxious barrage due to the neural trauma associated with these operations may be reduced in the perioperative period with the potential to reduce the risk of chronic pain.

Databases and data treatment

A systematic review of the evidence for perioperative interventions reducing acute and chronic pain associated with amputation, mastectomy or thoracotomy.

Results

Thirty-two randomized controlled trials met the inclusion criteria. Gabapentinoids reduced pain after mastectomy, but a single dose was ineffective for thoracotomy patients who had an epidural. Gabapentinoids were ineffective for vascular amputees with pre-existing chronic pain. Venlafaxine was associated with less chronic pain after mastectomy. Intravenous and topical lidocaine and perioperative EMLA (eutectic mixture of local anaesthetic) cream reduced the incidence of chronic pain after mastectomy, whereas local anaesthetic infiltration appeared ineffective. The majority of the trials investigating regional analgesia found it to be beneficial for chronic symptoms. Ketamine and intercostal cryoanalgesia offered no reduction in chronic pain. Total intravenous anaesthesia (TIVA) reduced the incidence of post-thoracotomy pain in one study, whereas high-dose remifentanil exacerbated chronic pain in another.

Conclusions

Appropriate dose regimes of gabapentinoids, antidepressants, local anaesthetics and regional anaesthesia may potentially reduce the severity of both acute and chronic pain for patients. Ketamine was not effective at reducing chronic pain. Intercostal cryoanalgesia was not effective and has the potential to increase the risk of chronic pain. TIVA may be beneficial but the effects of opioids are unclear.

Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis

BACKGROUND

Regional anaesthesia may reduce the risk of persistent (chronic) pain after surgery, a frequent and debilitating condition. We compared regional anaesthesia vs conventional analgesia for the prevention of persistent postoperative pain (PPP).

METHODS

We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and CINAHL from their inception to May 2012, limiting the results to randomized, controlled, clinical trials (RCTs), supplemented by a hand search in conference proceedings. We included RCTs comparing regional vs conventional analgesia with a pain outcome at 6 or 12 months. The two authors independently assessed methodological quality and extracted data. We report odds ratios (ORs) with 95% confidence intervals (CIs) as our summary statistic based on random-effects models. We grouped studies according to surgical interventions.

RESULTS

We identified 23 RCTs. We pooled data from 250 participants in three trials after thoracotomy with outcomes at 6 months. Data favoured epidural anaesthesia for the prevention of PPP with an OR of 0.33 (95% CI 0.20-0.56). We pooled two studies investigating paravertebral block for breast cancer surgery; pooled data of 89 participants with outcomes ≈ 6 months favoured paravertebral block with an OR of 0.37 (95% CI 0.14-0.94). Adverse effects were reported sparsely.

CONCLUSIONS

Epidural anaesthesia and paravertebral block, respectively, may prevent PPP after thoracotomy and breast cancer surgery in about one out of every four to five patients treated. Small numbers, performance bias, attrition, and incomplete outcome data especially at 12 months weaken our conclusions.

Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery

BACKGROUND

Regional anaesthesia may reduce the rate of persistent (chronic) pain after surgery, a frequent and debilitating condition.

OBJECTIVES

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent pain six or 12 months after surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), PubMed (1966 to April 2012), EMBASE (1966 to May 2012) and CINAHL (1966 to May 2012) without any language restriction. We used a combination of free text search and controlled vocabulary search. The results were limited to randomized controlled clinical trials (RCTs). We conducted a handsearch in reference lists of included trials, review articles and conference abstracts.

SELECTION CRITERIA

We included RCTs comparing local anaesthetics or regional anaesthesia versus conventional analgesia with a pain outcome at six or 12 months after surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. Results are presented as pooled odds ratios (OR) with 95% confidence intervals (CI), based on random-effects models (inverse variance method). We grouped studies according to surgical interventions. We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity.

MAIN RESULTS

We identified 23 RCTs studying local anaesthetics or regional anaesthesia for the prevention of persistent (chronic) pain after surgery. Data from a total of 1090 patients with outcomes at six months and of 441 patients with outcomes at 12 months were presented. No study included children. We pooled data from 250 participants after thoracotomy, with outcomes at six months. Data favoured regional anaesthesia for the prevention of chronic pain at six months after thoracotomy with an OR of 0.33 (95% CI 0.20 to 0.56). We pooled two studies on paravertebral block for breast cancer surgery; the pooled data of 89 participants with outcomes at five to six months favoured paravertebral block with an OR of 0.37 (95% CI 0.14 to 0.94).The methodological quality of the included studies was intermediate. Adverse effects were not studied systematically and were reported sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered the assessment of effects, especially at 12 months.

AUTHORS' CONCLUSIONS

Epidural anaesthesia may reduce the risk of developing chronic pain after thoracotomy in about one patient out of every four patients treated. Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about one out of every five women treated. Our conclusions are significantly weakened by performance bias, shortcomings in allocation concealment, considerable attrition and incomplete outcome data. We caution that our evidence synthesis is based on only a few, small studies. More studies with high methodological quality, addressing various types of surgery and different age groups, including children, are needed.

A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast

Background

In this prospective, randomized, placebo-controlled, double-blinded clinical trial we tested the hypothesis that preemptive analgesia with bupivacaine applied in the area of the surgical incision in patients undergoing mastectomy for breast cancer would reduce post-operative acute pain and would reduce the amount of analgesics used during surgery and in the post-operative period.

Material/Methods

Participants were assigned into 1 of 2 groups – with bupivacaine applied in the area of surgical incision or with placebo. We assessed the intraoperative consumption of fentanyl, the postoperative consumption of morphine delivered using a PCA method, and the subjective pain intensity according to VAS score reported by patients in the early post-operative period.

Results

Out of 121 consecutive cases qualified for mastectomy, 112 women were allocated randomly to 1 of 2 groups – group A (bupivacaine) and group B (placebo). The final study group comprised 106 breast cancer cases. Between the groups, a statistically significant difference was observed with respect to: lower fentanyl consumption during surgery (p=0.011), lower morphine (delivered by means of a PCA) consumption between the 4–12^th postoperative hours (p=0.02) and significantly lower pain intensity assessed according to VAS score at the 4^th and 12^th hours after surgery (p=0.004 and p=0.02 respectively) for the group A patients.

Conclusions

Preemptive analgesia application in the form of infiltration of the area of planned surgical incisions with bupivacaine in breast cancer patients undergoing mastectomy decreases post-operative pain sensation, limits the amount of fentanyl used during surgery, and reduces the demand for opiates in the hours soon after surgery.

A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection

Background

The effect of local infiltration after breast surgery is controversial. This prospective double blind randomized study sought to document the analgesic effect of local anaesthetic infiltration after breast cancer surgery.

Methods

Patients scheduled for mastectomy or tumorectomy and axillary nodes dissection had immediate postoperative infiltration of the surgical wound with 20 ml of ropivacaine 7.5 mg.ml^-1 or isotonic saline. Pain was assessed on a visual analogue scale at H2, H4, H6, H12, H24, H72, and at 2 month, at rest and on mobilization of the arm. Patient'comfort was evaluated with numerical 0-3 scales for fatigue, quality of sleep, state of mood, social function and activity.

Results

Twenty-two and 24 patients were included in the ropivacaine and saline groups respectively. Postoperative pain was lower at rest and on mobilization at 2, 4 and 6 hour after surgery in the ropivacaine group. No other difference in pain intensity and patient 'comfort scoring was documented during the first 3 postoperative days. Patients did not differ at 2 month for pain and comfort scores.

Conclusion

Single shot infiltration with ropivacaine transiently improves postoperative pain control after breast cancer surgery.

Trial registration number

NCT01404377