General anaesthesia versus thoracic paravertebral block for breast surgery: A meta-analysis

Advancing Reduction Mammaplasty Surgery: Advancements and Outcomes with Tumescent Local Anaesthesia

BACKGROUND

Tumescent local anaesthesia (TLA) is a method of anaesthesia used for surgical procedures that involves the infusion of a saline solution containing lidocaine, sodium bicarbonate, and epinephrine. This anaesthetic technique is designed to achieve both vasoconstriction and anaesthesia. In this article, we present a modified TLA protocol specifically adapted for reduction mammaplasty, based on an analysis of clinical case histories collected over the past few years.

METHODS

During the period from 2012 to 2022, we performed a reduction mammaplasty procedure in 120 patients employing tumescent local anaesthesia (TLA). The composition of the tumescent solution included 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. The solution was injected diffusely throughout the mammary gland.

RESULTS

The average volume of tumescent solution infiltrated during TLA was 350 mL per breast. There were no cases of adrenaline or lidocaine toxicity, and no patients required conversion to general anaesthesia. No patient received sedation. Patients reported no pain or discomfort during pre-operative infiltration or during surgery. No reinterventions were necessary because of short-term complications. Among the complications, there were 4 cases of hematoma (3,3%), 3 cases of seroma (2,55%), 10 cases of wound dehiscence (8,3%), 5 cases of asymmetry (4,1%), 9 cases of T-junction breakdown (7,5%), 2 cases of (partial) nipple necrosis (1,6%), and 3 cases of liponecrosis (2,5%). No cases of infection or total nipple-areola loss were reported. The follow-up period was between 30 days and 1 year.

CONCLUSIONS

Reduction mammaplasty is a viable surgical option for women with macromastia seeking to enhance their physiognomy. It is imperative that patients fully understand the potential benefits and risks associated with the procedure and consult with healthcare professionals specialising in this field. The use of tumescent local anaesthesia (TLA) has been confirmed as a safe and effective methodology to perform reduction mammaplasty, ensuring adequate pain control with minimal post-operative complications and resulting in a high degree of patient satisfaction.

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 .

Endoscopic Primary Breast Augmentation With Loco-Regional Anesthesia: Preliminary Experience of 200 Consecutive Patients

Background

Breast augmentation with implants recorded over 1.6 billion procedures globally in 2022. To reduce surgical trauma and complications and facilitate a fast recovery, we employ an ultrasound-guided local-regional anesthesia technique, the creation of a partial submuscular implant pocket by direct endoscopic visualization and minimal skin access on the mammary fold.

Objectives

The aim in this study is to evaluate whether breast augmentation performed in endoscopy under local-regional anesthesia reduces postoperative recovery time, reduces complications, and increases patient satisfaction.

Methods

Patients provided their consent through a signed form. We set strict inclusion and exclusion criteria. We prospectively evaluated postoperative pain and recovery times, the rate of complications, and patient satisfaction at 12 months postsurgery.

Results

Between January 2021 and September 2022, 200 patients met the inclusion criteria. The average operation time was 54.2 min. Patients were discharged from the hospital within 2 to 3 h. Eighty-nine percent of patients expressed great satisfaction with the result. None of the patients experienced postsurgical complications.

Conclusions

In our initial study, we showed that endoscopic breast augmentation conducted under localized anesthesia is safe. It allows for quick recovery postsurgery and swift resumption of everyday activities. The overall complication risk is less than what has been reported in scientific studies for the classic dual-plane technique. Moreover, this approach yields excellent patient satisfaction. Additional prospective and randomized studies will be required to enhance the scientific validity of this technique. Moreover, a larger patient cohort will be essential to stratify the risks associated with varying prosthetic volumes.

Level of Evidence 4

Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial

Background

Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients.

Aim

This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration.

Methods

We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery.

Results

Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant.

Conclusions

Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.

Efficacy of Serratus Anterior Plane Block Versus Paravertebral and Intercostal Blocks for Pain Control After Surgery:: A Systematic Review and Meta-analysis

OBJECTIVE

Our study aimed to compare the analgesic efficacy of serratus anterior plane block (SAB) with the paravertebral block (PVB) and intercostal block (ICB) for patients undergoing surgical procedures.

MATERIALS AND METHODS

A literature search was performed on the databases of ScienceDirect, Google Scholar, PubMed, and Embase from inception to October 24, 2021. Only randomized controlled trials comparing SAB with either PVB or ICB and reporting pain outcomes were included.

RESULTS

A total of 16 randomized controlled trials were included. Thirteen compared SAB with PVB and 3 with ICB. Comparing SAB with PVB, we noted no difference in 24-hour morphine consumption between the groups (mean difference: 1.37; 95% CI: -0.33, 3.08; I2 = 96%; P = 0.11). However, the exclusion of 1 study indicated significantly increased analgesic consumption with the SAB. No difference was found in pain scores between SAB and PVB at 2, 4, 6, 8, 12, and 24 hours. Meta-analysis failed to demonstrate any statistically significant difference in time to the first analgesic request between the two groups (mean difference: -0.79; 95% CI: -0.17, 1.75; I2 = 94%; P = 0.11). We also noted no statistically significant difference in the incidence of nausea/vomiting with SAB or PVB (odds ratio: 0.79; 95% CI: 0.41, 1.51; I2 = 0%; P = 0.47).

CONCLUSIONS

Evidence on the analgesic efficacy of the SAB versus the PVB is conflicting. Twenty-four-hour total analgesic consumption may be higher with the SAB as compared with PVB but with no difference in pain scores and time to the first analgesic request. Data on the comparison of the SAB with the ICB is insufficient to draw strong conclusions.

Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge

BACKGROUND

There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population.

METHODS

We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain.

RESULTS

Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block.

CONCLUSION

Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.

A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction

BACKGROUND

Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy.

METHOD

Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications.

RESULT

No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates.

CONCLUSION

Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks.

TRIAL REGISTRATION

This trial is registered with Clinical Research Information Service (NCT03653988).

Breast augmentation under local anesthesia with intercostal blocks and light sedation

INTRODUCTION

This study of breast augmentations performed under local anesthesia with intercostal blocks and light sedation describes the outcomes and evaluates benefits and complications.

METHOD

From December 2005 until August 2019, 335 women consecutively underwent bilateral breast augmentation procedures. The anesthetic protocol consisted of an initial intravenous bolus of 1 mg midazolam and 0.25 mg alfentanil preoperatively. In 2017, this was changed to 2-4 mg midazolam intramuscularly, 1 mg midazolam intravenously, and 2.5 µg sufentanil intravenously. Intercostal blocks were injected at the midaxillary line into the intercostal spaces two to seven. The operating field was infiltrated with tumescent local anesthesia. Retrospective data extraction from patients' medical charts was done, registering demographics, dosage of anesthesia, surgical characteristics, complications, and reoperation rates.

RESULTS

Two hundred and eighty-one women underwent primary augmentation and 54 had implant replacement. The most common complications included suboptimal cosmetic results, asymmetry, and healing-related problems. The overall rate of reoperation was 16.1% within an average follow-up period of 2 years, ranging from 0 to 12.5 years. The majority of the reoperations were due to cosmetic reasons. The change in anesthetic regime was associated with a significantly (p < 0.0001) decreased need for supplementary medication with no increased risk of complications.

CONCLUSION

Breast augmentations in local anesthesia with intercostal blocks and light sedation can be performed safely and can serve as an alternative to procedures in general anesthesia.

Analgesic effect of ketorolac as an adjuvant to bupivacaine in ultrasound-guided pectoral nerve block (I + II) for patients undergoing modified radical mastectomy: A randomized controlled clinical trial

Background and Aims

Many drugs have been tried as adjuvant to local anesthetic in different nerve blocks. Ketorolac is one of them, but it has never been used in pectoral nerve block. In this study, we evaluated its adjuvant effect with local anesthetic on postoperative analgesia in ultrasound (US)-guided pectoral nerve (PECS) blocks. The aim was to assess the quality and the duration of analgesia by the addition of ketorolac in the PECS block.

Material and Methods

46 patients who underwent modified radical mastectomies under general anesthesia were randomized into two groups: control group, where pectoral nerve block was given with bupivacaine 0.25% only; and ketorolac group, where the block was given with bupivacaine 0.25% and ketorolac 30 mg.

Results

Patients who needed postoperative supplemental analgesia were significantly less in the ketorolac group (9 vs 21 patients, P = 0.00) and that first-time analgesic requirement was significantly later in the ketorolac group (14 hrs) postoperatively compared to the control group (9 hrs) postoperatively.

Conclusion

Adding ketorolac to bupivacaine in pectoral nerve block safely increases postoperative duration of analgesia.

Evidence basis for using dexmedetomidine to enhance the quality of paravertebral block: A systematic review and meta-analysis of randomized controlled trials

Background: Dexmedetomidine is considered an adjunct to local anaesthesia (LA) to prolong peripheral nerve block time. However, the results from a previous meta-analysis were not sufficient to support its use in paravertebral block (PVB). Therefore, we performed an updated meta-analysis to evaluate the efficacy of dexmedetomidine combined with LA in PVB.

Methods: We performed an electronic database search from the date of establishment to April 2022. Randomized controlled trials (RCTs) investigating the combination of dexmedetomidine and LA compared with LA alone for PVB in adult patients were included. Postoperative pain scores, analgesic consumption, and adverse reactions were analyzed.

Results: We identified 12 trials (701 patients) and found that the application of dexmedetomidine as a PVB adjunct reduced the postoperative pain severity of patients 12 and 24 h after surgery compared to a control group. Expressed as mean difference (MD) (95% CI), the results were −1.03 (−1.18, −0.88) (p < 0.00001, I² = 79%) for 12 h and −1.08 (−1.24, −0.92) (p < 0.00001, I² = 72%) for 24 h. Dexmedetomidine prolonged the duration of analgesia by at least 173.27 min (115.61, 230.93) (p < 0.00001, I² = 81%) and reduced postoperative oral morphine consumption by 18.01 mg (−22.10, 13.92) (p < 0.00001, I² = 19%). We also found no statistically significant differences in hemodynamic complications between the two groups. According to the GRADE system, we found that the level of evidence for postoperative pain scores at 12 and 24 h was rated as moderate.

Conclusion: Our study shows that dexmedetomidine as an adjunct to LA improves the postoperative pain severity of patients after surgery and prolongs the duration of analgesia in PVB without increasing the incidence of adverse effects.

Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy

BACKGROUND

As plastic surgeons continue to evaluate the utility of nonopioid analgesic alternatives, nerve block use in breast plastic surgery remains limited and unstandardized, with no syntheses of the available evidence to guide consensus on optimal approach.

METHODS

A systematic review was performed to evaluate the role of pectoralis nerve blocks, paravertebral nerve blocks, transversus abdominus plane blocks, and intercostal nerve blocks in flap-based breast reconstruction, prosthetic-based reconstruction, and aesthetic breast plastic surgery, independently.

RESULTS

Thirty-one articles reporting on a total of 2820 patients were included in the final analysis; 1500 patients (53 percent) received nerve blocks, and 1320 (47 percent) served as controls. Outcomes and complications were stratified according to procedures performed, blocks employed, techniques of administration, and anesthetic agents used. Overall, statistically significant reductions in opioid consumption were reported in 91 percent of studies evaluated, postoperative pain in 68 percent, postanesthesia care unit stay in 67 percent, postoperative nausea and vomiting in 53 percent, and duration of hospitalization in 50 percent. Nerve blocks did not significantly alter surgery and/or anesthesia time in 83 percent of studies assessed, whereas the overall, pooled complication rate was 1.6 percent.

CONCLUSIONS

Transversus abdominus plane blocks provided excellent outcomes in autologous breast reconstruction, whereas both paravertebral nerve blocks and pectoralis nerve blocks demonstrated notable efficacy and versatility in an array of reconstructive and aesthetic procedures. Ultrasound guidance may minimize block-related complications, whereas the efficacy of adjunctive postoperative infusions was proven to be limited. As newer anesthetic agents and adjuvants continue to emerge, nerve blocks are set to represent essential components of the multimodal analgesic approach in breast plastic surgery.

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control.

Methods

A review study based on multimodal analgesia was conducted.

Results

We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices.

Conclusion

This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

Use of ultrasound guided single shot costotransverse block (intertransverse process) in breast cancer surgery: a prospective, randomized, assessor blinded, controlled clinical trial

BACKGROUND

Ultrasound guided costotransverse block (CTB) is a relatively new "peri-paravertebral" block that has been described recently. It has been previously reported that CTB, administered with a single high-volume injection, provides effective analgesia in breast conserving surgery. In this study we evaluated the effect of CTB when used in breast cancer surgery.

METHODS

Seventy patients due to undergo breast cancer surgery were included in this blinded, prospective, randomized, efficiency study. Patients were randomized into two equal groups (CTB group and control group) using the closed envelope technique. All patients underwent general anesthesia. In addition to standard analgesia methods, patients in group CTB also received CTB block while the remaining (control group) did not. Numeric rating (pain) scores and opioid consumption was compared between the two groups.

RESULTS

Opioid consumption in all time frames and pain scores at 1st and 3rd hours only were found to be significantly lower in Group CTB when compared to the control group.

CONCLUSIONS

Ultrasound guided CTB improves analgesia quality in breast cancer surgery.

TRIAL REGISTRATION

Clinicaltrials Registration ID: NCT04197206 , Registration Date: 13/12/2019.

Prediction of total hospital expenses of patients undergoing breast cancer surgery in Shanghai, China by comparing three models

BACKGROUND

Breast cancer imposes a considerable burden on both the health care system and society, and becomes increasingly severe among women in China. To reduce the economic burden of this disease is crucial for patients undergoing the breast cancer surgery, hospital managers, and medical insurance providers. However, few studies have evidenced the prediction of the total hospital expenses (THE) for breast cancer surgery. The aim of the study is to predict THE for breast cancer surgery and identify the main influencing factors.

METHODS

Data were retrieved from the first page of medical records of 3699 patients undergoing breast cancer surgery in one tertiary hospital from 2017 to 2018. Multiple liner regression (MLR), artificial neural networks (ANNs), and classification and regression tree (CART) were constructed and compared.

RESULTS

The dataset from 3699 patients were randomly divided into training and test sets at a 70:30 ratio (2599 and 1100 records, respectively). The average total hospital expenses were 12520.54 ± 7844.88 ¥ (US$ 1929.20 ± 1208.11). MLR results revealed six factors to be significantly associated with THE: age, LOS, type of disease, having medical insurance, minimally invasive surgery, and receiving general anesthesia. After comparing three models, ANNs was the best model to predict THEs in patients undergoing breast cancer surgery, and its strong predictive performance was also validated.

CONCLUSIONS

To reduce the THEs, more attention should be paid to related factors of LOS, major and minimally invasive surgeries, and general anesthesia for these patient groups undergoing breast cancer surgery. This may reduce the information asymmetry between doctors and patients and provide more reliable cost, practical inpatient medical consumption standards and reimbursement standards reference for patients, hospital managers, and medical insurance providers ,respectively.

Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB).

METHODS

We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software.

RESULTS

We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006).

CONCLUSION

Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.

Post-Mastectomy Pain: An Updated Overview on Risk Factors, Predictors, and Markers

After breast surgery, women frequently develop chronic post-mastectomy pain (PMP). PMP refers to the occurrence of pain in and around the area of the mastectomy lasting beyond three months after surgery. The nature of factors leading to PMP is not well known. When PMP is refractory to analgesic treatment, it negatively impacts the lives of patients, increasing emotional stress and disability. For this reason, optimizing the quality of life of patients treated for this pathology has gained more importance. On the basis of the findings and opinions above, we present an overview of risk factors and predictors to be used as potential biomarkers in the personalized management of individual PMP. For this overview, we discuss scientific articles published in peer-reviewed journals written in the English language describing risk factors, predictors, and potential biomarkers associated with chronic pain after breast surgery. Our overview confirms that the identification of women at risk for PMP is fundamental to setting up the best treatment to prevent this outcome. Clinical practice can be planned through the interpretation of genotyping data, choosing drugs, and tailoring doses for each patient with the aim to provide safer and more effective individual analgesic treatment.

Thoracic Paravertebral Nerve Block with Ropivacaine and Adjuvant Dexmedetomidine Produced Longer Analgesia in Patients Undergoing Video-Assisted Thoracoscopic Lobectomy: A Randomized Trial

Purpose

This study evaluated the postoperative analgesic effect of ultrasound-guided single-point thoracic paravertebral nerve block (TPVB) combined with dexmedetomidine (DEX) in patients undergoing video-assisted thoracoscopic lobectomy.

Methods

Sixty adult patients of the American Society of Anesthesiologists (ASA) I-III were randomly assigned into three groups (n = 20 each). G group: patients received routine general anesthesia; PR group: patients received 0.5% ropivacaine; and PRD group: patients received 0.5% ropivacaine with 1 μg/kg DEX. TPVB was performed in the T5 space before surgery, and then, general anesthesia induction and video-assisted thoracoscopic lobectomy were performed. Analgesics were administered through the patient-controlled analgesia (PCA) device intravenously. The background infusion of each PCA device was set to administer 0.02 μg/kg/h sufentanil, with a lockout time of 15 min, and a total allowable volume is 100 ml.

Results

Compared to PR and G groups, the total sufentanil consumption after operation, the times of analgesic pump pressing, the pain score, and the incidence of postoperative nausea or vomiting in the PRD group were significantly reduced (p < 0.05). Also, the duration of first time of usage of the patient-controlled analgesia (PCA) was longer. The heart rate (HR) and mean arterial pressure (MAP) during operation were lower in the PRD group as compared with the other two groups in most of the time. However, hypotension and arrhythmia occurred in three groups with no statistically significant difference.

Conclusions

A small volume of TPVB with ropivacaine and DEX by single injection produced longer analgesia in patients undergoing video-assisted thoracoscopic lobectomy, reduced postoperative opioids consumption, and the incidence of side effects.

Breast Regional Anesthesia Practice in the Italian Public Health System (BRA-SURVEY): A Survey-Based National Study

BACKGROUND

Breast cancer is the most common malignancy in women. Surgery is a mainstay therapy unfortunately burdened by complications as severe postoperative pain. Regional anesthesia may play a role in a multimodal strategy for prevention and treatment of postoperative pain. The main purpose of this survey was to investigate the rate of use of regional anesthesia techniques in patients undergoing breast surgery in the Italian public hospital system.

METHODS

We designed an online survey that consisted of 22 questions investigating the anesthesia management of breast surgery, particularly focused on regional anesthesia. The survey lasted from November 18, 2019 to February 28, 2020. Directors of anesthesia departments of 168 Italian public health system hospitals were contacted and invited to forward the survey to every anesthesiologist in their unit.

RESULTS

A total of 935 anesthesiologists received the survey; among them 460 entered the final analysis. Regional anesthesia was not used by 44.6% of the anesthesiologists and lack of experience/training was the main cause (75.6%). Logistic regression models revealed that anesthesiologists with more than 15 years of experience (odds ratio [OR] = 0.55; 95% confidence interval [CI], 0.33-0.93) or working most of their days in intensive care unit (ICU) compared to operating theater (OR = 0.25; 95% CI, 0.14-0.43) were less likely to perform regional anesthesia techniques.

CONCLUSIONS

Low implementation of regional anesthesia techniques in breast surgery emerges from our survey and the major reason cited is a lack of proper training. An improved training program in regional anesthesia, especially in residents' curricula, could be useful to increase its rate of use and to standardize its practice.

Chest Wall Regional Anesthesia for Modified Radical Mastectomy and Axillary Lymph Node Dissection: A Case Report

Restrictive chest wall disorders impair cardiopulmonary physiology and pose anesthesia-related safety challenges. Regional anesthesia, as the primary anesthetic modality, may mitigate general anesthesia-related risks in such patients presenting for breast cancer surgery. We describe the use of chest wall fascial plane blocks as the primary anesthetic, combined with high-flow humidified nasal oxygen and low-dose propofol sedation, in a patient with complex comorbidities presenting for modified radical mastectomy and axillary lymph node dissection.

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

BACKGROUND

Breast cancer is one of the most common cancers among women. Surgical removal of the cancer is the mainstay of treatment; however, tumour handling during surgery can cause microscopic dissemination of tumour cells and disease recurrence. The body's hormonal response to surgery (stress response) and general anaesthesia may suppress immunity, promoting tumour dissemination. Paravertebral anaesthesia numbs the site of surgery, provides good analgesia, and blunts the stress response, minimising the need for general anaesthesia.

OBJECTIVES

To assess the effects of paravertebral anaesthesia with or without sedation compared to general anaesthesia in women undergoing breast cancer surgery, with important outcomes of quality of recovery, postoperative pain at rest, and mortality.

SEARCH METHODS

On 6 April 2020, we searched the Specialised Register of the Cochrane Breast Cancer Group (CBCG); CENTRAL (latest issue), in the Cochrane Library; MEDLINE (via OvidSP); Embase (via OvidSP); the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal; and ClinicalTrials.gov for all prospectively registered and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) conducted in adult women undergoing breast cancer surgery in which paravertebral anaesthesia with or without sedation was compared to general anaesthesia. We did not include studies in which paravertebral anaesthesia was given as an adjunct to general anaesthesia and then this was compared to use of general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted details of trial methods and outcome data from eligible trials. When data could be pooled, analyses were performed on an intention-to-treat basis, and the random-effects model was used if there was heterogeneity. When data could not be pooled, the synthesis without meta-analysis (SWiM) approach was applied. The GRADE approach was used to assess the certainty of evidence for each outcome.

MAIN RESULTS

Nine studies (614 participants) were included in the review. All were RCTs of parallel design, wherein female patients aged > 18 years underwent breast cancer surgery under paravertebral anaesthesia or general anaesthesia. None of the studies assessed quality of recovery in the first three postoperative days using a validated questionnaire; most assessed factors affecting quality of recovery such as postoperative analgesic use, postoperative nausea and vomiting (PONV), hospital stay, ambulation, and patient satisfaction. Paravertebral anaesthesia may reduce the 24-hour postoperative analgesic requirement (odds ratio (OR) 0.07, 95% confidence interval (CI) 0.01 to 0.34; 5 studies, 305 participants; low-certainty evidence) compared to general anaesthesia. Heterogeneity (I² = 70%) was attributed to the fixed dose of opioids and non-steroidal analgesics administered postoperatively in one study (70 participants), masking a difference in analgesic requirements between groups. Paravertebral anaesthesia probably reduces the incidence of PONV (OR 0.16, 95% CI 0.08 to 0.30; 6 studies, 324 participants; moderate-certainty evidence), probably results in a shorter hospital stay (mean difference (MD) -79.39 minutes, 95% CI -107.38 to -51.40; 3 studies, 174 participants; moderate-certainty evidence), and probably reduces time to ambulation compared to general anaesthesia (SWiM analysis): percentages indicate vote counting based on direction of effect (100%, 95% CI 51.01% to 100%; P = 0.125; 4 studies, 375 participants; moderate-certainty evidence). Paravertebral anaesthesia probably results in higher patient satisfaction (MD 5.52 points, 95% CI 1.30 to 9.75; 3 studies, 129 participants; moderate-certainty evidence) on a 0 to 100 scale 24 hours postoperatively compared to general anaesthesia. Postoperative pain at rest and on movement was assessed at 2, 6, and 24 postoperative hours on a 0 to 10 visual analogue scale (VAS). Four studies (224 participants) found that paravertebral anaesthesia as compared to general anaesthesia probably reduced pain at 2 postoperative hours (MD -2.95, 95% CI -3.37 to -2.54; moderate-certainty evidence). Five studies (324 participants) found that paravertebral anaesthesia may reduce pain at rest at 6 hours postoperatively (MD -1.54, 95% CI -3.20 to 0.11; low-certainty evidence). Five studies (278 participants) found that paravertebral anaesthesia may reduce pain at rest at 24 hours postoperatively (MD -1.19, 95% CI -2.27 to -0.10; low-certainty evidence). Differences in the methods of two studies (119 participants) and addition of clonidine to the local anaesthetic in two studies (109 participants), respectively, contributed to the heterogeneity (I² = 96%) observed for these two outcomes. Two studies (130 participants) found that paravertebral anaesthesia may reduce pain on movement at 6 hours (MD-2.57, 95% CI -3.97 to -1.17) and at 24 hours (MD -2.12, 95% CI -4.80 to 0.55; low-certainty evidence). Heterogeneity (I² = 96%) was observed for both outcomes and could be due to methodological differences between studies. None of the studies reported mortality related to the anaesthetic technique. Eight studies (574 participants) evaluated adverse outcomes with paravertebral anaesthesia: epidural spread (0.7%), minor bleeding (1.4%), pleural puncture not associated with pneumothorax (0.3%), and Horner's syndrome (7.1%). These complications were self-limiting and resolved without treatment. No data are available on disease-free survival, chronic pain, and quality of life. Blinding of personnel or participants was not possible in any study, as a regional anaesthetic technique was compared to general anaesthesia. Risk of bias was judged to be serious, as seven studies had concerns of selection bias and three of detection bias.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that paravertebral anaesthesia probably reduces PONV, hospital stay, postoperative pain (at 2 hours), and time to ambulation and results in greater patient satisfaction on the first postoperative day compared to general anaesthesia. Paravertebral anaesthesia may also reduce postoperative analgesic use and postoperative pain at 6 and 24 hours at rest and on movement based on low-certainty evidence. However, RCTs using validated questionnaires are needed to confirm these results. Adverse events observed with paravertebral anaesthesia are rare.

＜Editors' Choice＞ Efficacy of pectoral nerve block type-2 (Pecs II block) versus serratus plane block for postoperative analgesia in breast cancer surgery: a retrospective study

Thoracic wall nerve blocks reduce postoperative acute pain after breast cancer surgery (BCS); however, their short-term effects and the most effective technique remain unclear. To compare the effects of pectoral nerve block type-2 (Pecs II block) and serratus plane block for postoperative short-term analgesia, we retrospectively reviewed 43 BCS patients who underwent Pecs II block (n=22) or serratus plane block (n=21). The primary outcome was the proportion of patients with no complaints of pain 2 months post-BCS. The odds ratio (OR) was assessed, adjusting for axillary lymph node dissection. The secondary outcomes were pain severity 24 hours and 2 months post-operation using the numerical rating scale score, and morphine consumption within 24 hours. The proportion of patients without pain 2 months post-BCS was significantly less with Pecs II block than in patients with serratus plane block (55% vs. 19%, adjusted OR, 5.04; 95% confidence interval, 1.26-20.07; P=0.02); the median [interquartile range] score for pain 2 months post-operation was also significantly lower with Pecs II block (Pecs II block 0.5 [0-1] vs. serratus plane block 1 [1-2]); P=0.03). Regarding post-BCS acute analgesia, the median [interquartile range] postoperative 24-hour pain score was 2 [1-3] and 3 [1.5-3.5], and the median morphine consumption within 24 hours was 1.5 [0.75-5.5] and 3 [1.5-10] mg in Pecs II block and serratus plane block (P=0.47 and P=0.11), respectively. This study suggests that Pecs II block prevents short-term post-BCS pain better than serratus plane block. However, further studies are needed in order to support this finding.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery: A meta-analysis

BACKGROUND

The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis.

METHODS

Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software.

RESULTS

Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = -0.65) and morphine (total: SMD = -2.23; patient-controlled analgesia: SMD = -1.45) as well as intraoperative requirement for fentanyl (SMD = -1.60), and lower the pain score at 1 (SMD = -0.30), 2 (SMD = -1.45), 4 (SMD = -2.36), 6 (SMD = -0.63), 8 (SMD = -2.47), 12 (SMD = -0.81), 24 (SMD = -1.78), 36 (SMD = -0.92), and 48 (SMD = -0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup (P < .05) relative to local anesthesia subgroup (P >.05).

CONCLUSION

DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.

Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery

Purpose

Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1–T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS.

Patients and Methods

Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1–0.5 µg.kg⁻¹.h⁻¹) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA.

Results

The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia.

Conclusion

USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

Preemptive Analgesic Efficacy of the Ultrasound-Guided Bilateral Superficial Serratus Plane Block on Postoperative Pain in Breast Reduction Surgery: A Prospective Randomized Controlled Study

PURPOSE

Breast surgery is an exceedingly common procedure and associated with an increased incidence of acute and chronic pain. Preemptive regional anesthesia techniques may improve postoperative analgesia for patients undergoing breast surgery. The aim of this study was to evaluate the effect of preoperative bilateral serratus plane block on postoperative opioid consumption in patients undergoing breast reduction surgery.

METHODS

After ethical board approval, 40 patients undergoing breast reduction surgery were randomized into 2 groups: control group (Group C, n = 20) and serratus plane block group (Group SPB, n = 20). Group C received bilateral ultrasound-guided 2 ml 0.9% saline subcutaneously each block side, Group SPB received ultrasound-guided bilateral SPB with 0.25% bupivacaine 30 ml each side. The groups were administered the routine general anesthesia protocol. All operations were performed with the mediocentral pedicled reduction mammaplasty technique by the same surgeon. Postoperative analgesia was performed intravenously in the 2 groups twice a day with dexketoprofen trometamol 50 mg and patient-controlled analgesia with fentanyl. Postoperative analgesia was evaluated using the visual analog scale (VAS). Fentanyl consumption, additional analgesia requirement and opioid-related side effects were recorded during the first 24 h after surgery.

RESULTS

Compared with control, the VAS score was statistically lower in the SPB group during all measurement times (p < 0.05). The 24-h opioid consumption was significantly higher in the control group compared with the SPB group (372.50 ± 39.65 vs. 296.25 ± 58.08 μq, respectively; p < 0.001). In addition, the analgesia requirement was statistically lower in the SPB group (8/20 vs. 2/20, respectively, p < 0.028). Nausea or vomiting was observed more often in the control group than in SPB block (9/20 vs. 2/20, respectively, p = 0.013), whereas other side effects were similar for the two groups.

CONCLUSIONS

SPB can be used safely bilaterally in the management of pain for breast reduction surgery as it is easy to perform, provides excellent analgesia, and reduces opioid consumption and opioid sparing effect.

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.

Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review

With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.

Single shot ultrasound-guided thoracic paravertebral block for opioid-free radical mastectomy: a prospective observational study

Background

General anesthesia (GA) is the most commonly used anesthesiological technique for radical mastectomy operations and can be associated with loco-regional anesthesia techniques. The aim of our study, carried out on 51 patients, was to assess the effectiveness of thoracic paravertebral block (TPVB) associated with GA, or as a sole anesthesiological technique for postoperative pain control and for the reduction of intra and postoperative opioids consumption.

Materials and methods

Fifty-one patients with neoplastic breast disease and elected as candidates for radical mastectomy were included in the study. The primary outcomes for this study were intra and postoperative opioid consumption and postoperative pain intensity. In 37 patients, TPVB was associated with GA while in 14 patients it was used as the sole anesthesiological technique. Data are reported as mean with standard deviation median with interquartile range, number, and percentage, depending on the underlying distribution.

Results

We did not use intra or postoperative opioids for any patient and the Numeric Rate Scale, assessed at time 0, at the end of the surgery, and 2, 6, 12, and 24 hrs after surgery, was >3 in seven patients only.

Conclusions

This study aims to show how TPVB can be used to carry out radical mastectomy procedures so that intra and postoperative opioids use can be avoided. In our study, TPVB was used in total mastectomy procedures in association with GA or as the sole anesthesiological technique, without the intra and postoperative use of opioids and with a significant reduction of local anesthetic dosages compared to those reported in the existing literature.

Non-narcotic Perioperative Pain Management in Prosthetic Breast Reconstruction During an Opioid Crisis: A Systematic Review of Paravertebral Blocks

Background:

Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer–related surgeries. However, a specific understanding of PVB’s efficacy in pain management in patients who undergo IBR is lacking.

Methods:

A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay.

Results:

The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption.

Conclusion:

PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.

Pectoral nerve block in anesthesia for modified radical mastectomy: A meta-analysis based on randomized controlled trials

BACKGROUND

Many types of regional nerve blocks have been used during anesthesia for modified radical mastectomy. In recent years, the use of pectoral nerve (PECS) block has gained importance in postoperative analgesia, but there are still controversies regarding its efficacy. There is especially no consensus on the optimal type of PECS block to be used. Herein, we attempt to evaluate the analgesic efficacy of the PECS block after radical mastectomy.

METHODS

We searched PubMed, EMBASE, and the Cochrane library for randomized controlled trials (RCTs) for studies regarding PECS versus general anesthesia (GA) that were published prior to May 31, 2018. Outcome measures such as intra- and postoperative consumption of opioids, postoperative nausea and vomiting (PONV), need for postoperative rescue analgesia, and pain scores were analyzed. After quality evaluation and data extraction, a meta-analysis was performed using Review Manager 5.3 software, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used for rating the quality of evidence.

RESULTS

A total of 8 RCTs and 2 cohort studies involving 993 patients were eligible. Compared with the GA group, the PECS block group effectively reduced the intraoperative and postoperative use of opioid drugs, incidence of PONV, need for postoperative rescue analgesia, and pain scores within 0 to 6 hours after surgery. However, subgroup analysis showed that PECS I block did not have a significant advantage in reducing the intra- and postoperative consumption of opioids. Results for each outcome indicator were confirmed as having a high or moderate level of evidence.

CONCLUSIONS

Even considering the limitations (evaluations of efficacy in different age groups and for chronic pain were not carried out) of this meta-analysis, it can be concluded that the PECS II block is an effective anesthetic regimen in modified radical mastectomy that can effectively reduce the intra- and postoperative consumption of opioids, postoperative PONV, and the need for postoperative rescue analgesia and can alleviate early pain (0-6 hours) after surgery.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia

BACKGROUND

Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7 years.

METHODS

From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle.

RESULTS

The average amount of tumescent solution infiltrated while performing TLA was 740 mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation).

CONCLUSIONS

TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied.

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 .

Tumescent Local Infiltration Anesthesia for Mini Abdominoplasty with Liposuction

AIM:

To evaluate the feasibility and safety of mini abdominoplasty with liposuction under local tumescent anaesthesia (LA) as the sole anaesthetic modality.

METHODS:

The study included 60 female patients with a mean age of 33.3 ± 5.6 years. Local infiltration using a mixture of 1:1000 epinephrine (1 ml), 2% lidocaine (100 ml) and 0.5% Levobupivacaine (50 ml) in 2500 ml saline was started with Local infiltration started with the abdomen, outer thigh, hips, back, inner thighs and knees. After Mini Abdominoplasty with supplemental liposuction was conducted and application of suction drains wound closure was performed, and the tight bandage was applied. Pain during injection, incision and surgical manipulations was determined. Duration of postoperative analgesia, till oral intake and return home, patients and surgeon satisfaction scores were determined.

RESULTS:

All surgeries were conducted completely without conversion to general anaesthesia. Injection pain was mild in 46 patients, moderate in 10 and hardly tolerated in 4 patients. Incision pain was mild in 16 patients, while 44 patients reported no sensation. During the surgical procedure, 6 patients required an additional dose of LA. Meantime till resumption of oral intake was 1.6 ± 0.9 hours. Meantime till home return was 5.6 ± 2.4 hours. Twelve patients were highly satisfied, 18 patients were satisfied, and these 42 patients were willing to repeat the trial if required. Eight patients found the trial is good and only one patient refused to repeat the trial and was dissatisfied, for a mean total satisfaction score of 3.1 ± 0.9.

CONCLUSION:

Mini Abdominoplasty with liposuction could be conducted safely under tumescent LA with mostly pain-free intraoperative and PO courses and allowed such surgical procedure to be managed as an office procedure. The applied anaesthetic procedure provided patients’ satisfaction with varying degrees in about 97% of studied patients.

Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: A randomized controlled study

STUDY OBJECTIVE

To evaluate the analgesic effect of ultrasound-guided erector spinae plane (ESP) block in breast cancer surgery.

DESIGN

Randomized controlled, single-blinded trial.

SETTING

Operating room.

PATIENTS

Fifty ASA I-II patients aged 25-65 and scheduled for elective breast cancer surgery were included in the study.

INTERVENTIONS

Patients were randomized into two groups, ESP and control. Single-shot ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine at the T4 vertebral level was performed preoperatively to all patients in the ESP group. The control group received no intervention. Patients in both groups were provided with intravenous patient-controlled analgesia device containing morphine for postoperative analgesia.

MEASUREMENTS

Morphine consumption and numeric rating scale (NRS) pain scores were recorded at 1, 6, 12 and 24 h postoperatively.

MAIN RESULTS

Morphine consumption at postoperative hours 1, 6, 12 and 24 decreased significantly in the ESP group (p < 0.05 for each time interval). Total morphine consumption decreased by 65% at 24 h compared to the control group (5.76 ± 3.8 mg vs 16.6 ± 6.92 mg). There was no statistically significant difference between the groups in terms of NRS scores.

CONCLUSIONS

Our study findings show that US-guided ESP block exhibits a significant analgesic effect in patients undergoing breast cancer surgery. Further studies comparing different regional anesthesia techniques are needed to identify the optimal analgesia technique for this group of patients.

Comparison of Morphine and Clonidine as Adjuvants in Paravertebral Block

BACKGROUND

General anesthesia (GA) has been considered as the gold standard for breast cancer surgery. The problem of postoperative pain as well as the high incidence of nausea and vomiting has led to the search for a better modality for pain management with fewer side effects. In the last few years, paravertebral block (PVB) has gained immense popularity either in combination with GA or by itself for the anesthetic management of patients undergoing breast surgery.

CONTEXT

Paravertebral block in breast surgery.

AIMS

This study aims to evaluate the efficacy and duration of postoperative analgesia provided by ultrasound (USG)-guided PVB with bupivacaine and morphine versus bupivacaine and clonidine in patients undergoing modified radical mastectomy (MRM).

SUBJECT AND METHODS

In the study, 70 patients who were scheduled for MRM were enrolled and randomly divided into Group M (n = 35) and Group C (n = 35). Both groups received USG-guided PVB at T2-T3 after administering GA. Group M received 2 mg/kg 0.5% bupivacaine with 0.05 mg/kg morphine and Group C received 2 mg/kg 0.5% bupivacaine with 1 μg/kg clonidine in the block. Postoperatively, pain intensity was recorded using the visual analog scale (VAS) (0-10 scale) at 1, 2, 6, 18, and 24 h duration when patients were resting and during a standardized movement. Modified Post Anaesthesia Discharge Scoring System was assessed at 1, 2, 6, 18 and 24 h after surgery.

RESULTS

In this study conducted on 70 patients, VAS scores (both at rest and on movement) were found comparable at postoperative 1, 2, 6, 18, and 24 h (P > 0.05). There was no statistical difference in comparing postanesthesia discharging scoring in both the groups. No incidence of postoperative nausea and vomiting was seen in any group.

CONCLUSIONS

Morphine and clonidine in PVB are equally effective, and there is no superiority of one agent over the other. Hence, both drugs may be used with equal efficacy as adjuvants to bupivacaine in PVB for providing postoperative analgesia.

A Systematic Quality Evaluation of Meta-Analyses Related to Plastic Surgery

INTRODUCTION

Meta-analyses are considered to be an important source of evidence. This review aims to systematically assess the quality of meta-analyses addressing topics in plastic surgery.

METHODS

Electronic databases were selected for systematic review. A search was performed focusing on communication addresses containing terms related to plastic surgery, and detailed inclusion criteria were used. Related data were extracted and recorded according to the items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. To assess the quality of the meta-analyses over time, studies published before and after PRISMA were evaluated.

RESULTS

A total of 116 meta-analyses were included. There was 1 study that was fully in compliance with the PRISMA items. The main flaws impacting the overall quality of the included studies were in the following areas: structured summary (48%), protocol and registration (2%), full electronic search strategy (35%), risk of bias in individual studies (41%), additional analyses (27%), risk of bias within studies (47%), additional analysis (30%), and funding (47%). Study quality was evaluated using relative risks (RR) with a 95% confidence interval (95% CI); this revealed that there were few significant improvements in adherence to the PRISMA statement after its release, especially in selection (RR, 1.80; 95% CI, 1.08-2.99), results of individual studies (RR, 2.88; 95% CI, 1.41-5.91), synthesis of results (RR, 3.08; 95% CI, 1.32-7.17), and funding (RR, 1.65; 95% CI, 1.21-2.24).

CONCLUSIONS

There have been measurable improvements in the quality of meta-analyses over recent years. However, several serious deficiencies remain according to the PRISMA statement. Future reviewers should pay more attention to not only reporting the main findings but also encouraging compliance with proper standards.

A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone

AIM

To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics.

METHOD

A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale.

RESULTS

Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001).

CONCLUSION

The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.

Thoracic paravertebral regional anesthesia for pain relief in patients with breast cancer surgery

BACKGROUND

The present study aimed to assess the efficacy and safety of thoracic paravertebral regional anesthesia (TPVBRA) in patients with breast cancer surgery.

METHODS

In total, 72 patients undergoing breast cancer surgery were randomly divided into an intervention group and a control group; each group contained 36 subjects. Both groups received TPVBRA with 20 mL 0.25% bupivacaine. In addition, subjects in the intervention group also received an additional 1 μg/kg dexmedetomidine. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), pain intensity (measured by visual analogue scale, VAS), and analgesic consumption were assessed; adverse events were also recorded.

RESULTS

Significant differences were observed in HR (P < .05), SBP (P < .05), and DBP (P < .05) at the 30-minute point during surgery between the 2 groups. In addition, the time of the first administration of analgesia (P = .043) and the mean consumption of analgesic agents (P = .035) in the intervention group were much better than those in the control group. However, no significant differences in HR or VAS were found at any time point after surgery (P > .05). Furthermore, similar adverse events were detected in both groups (P > .05).

CONCLUSION

The results of this study showed that TPVBRA combined with bupivacaine and dexmedetomidine can enhance the duration and quality of analgesia without serious adverse events.

The Trajectory of Postoperative Pain Following Mastectomy with and without Paravertebral Block

Evidence to support the argument that general anesthesia (GA) with paravertebral block (PVB) provides better pain relief for mastectomy patients than GA alone is contradictory. The aim of this study was to explore pain and analgesia after mastectomy with or without PVB during acute inpatient recovery. A retrospective study was conducted in a single hospital providing specialist cancer services in metropolitan Melbourne, Australia. We explored pain and concomitant analgesic administration in 80 consecutive women recovering from mastectomy who underwent GA with (n = 40) or without (n = 40) PVB. A pain management index (PMI) was derived to illustrate the efficacy of management from day of surgery (DOS) to postoperative day (POD) 3. Patients who reported no pain progressively increased from DOS (n = 12, 15%) to POD 3 (n = 54, 67.5%). Most patients were administered analgesics as a combination of acetaminophen and a strong opioid on DOS (n = 53, 66.2%), POD 1 (n = 45, 56.2%), POD 2 (n = 33, 41.2%), and POD 3 (n = 21, 26.2%). Less than 6% of patients on any POD were administered multimodal anlagesics. PMI scores indicate some pain in the context of receiving weak and strong opioids for GA patients and more frequent use of nonopioid analgesics in PVB patients during recovery. These findings highlight the need for data describing patterns of analgesic administration in addition to reports of postoperative pain to determine the most effective means of avoiding postoperative pain in patients who require mastectomy.

Effect of Clonidine as Adjuvant in Thoracic Paravertebral Block for Patients Undergoing Breast Cancer Surgery: A Prospective, Randomized, Placebo-controlled, Double-blind Study

Background and Aims

Postoperative pain after breast cancer surgery is unavoidable. Thoracic paravertebral block (TPVB), a locoregional anesthetic technique, has been proven successful for postoperative pain management in different thoracic surgical procedures, such as thoracotomy, breast cancer surgeries. Clonidine, an adjuvant, in TPVB may enhance the quality and prolong the duration of analgesia. This prospective study was to evaluate the effectiveness of clonidine; administered with TPVB; in addition to conventional local anesthetic solution.

Materials and Methods

Fifty-two patients (25-55 years) scheduled for breast cancer surgery under general anesthesia were randomly divided into Group A (n = 26) receiving preoperative TPVB at T₃ with clonidine added to local anesthesia solution and Group B (n = 26) receiving identical TPVB with local anesthesia but without any adjuvant. This was followed by balanced general anesthesia. A visual analog scale was used to assess pain postoperatively up to 48 h. Meantime to administration of the first dose of rescue analgesic was noted. Total dose of fentanyl consumption, hemodynamic parameters, and side effects were all recorded for each patient.

Results

The dosage of fentanyl required in the intraoperative period was significantly lower in Group A. Mean time to administration of rescue analgesic was found to be significantly longer in clonidine group. Hemodynamics and side effects were quite comparable among two groups.

Conclusion

Clonidine as adjuvant in TPVB provided profound analgesia for up to 48 h postoperatively for patients undergoing breast cancer surgery without any appreciable side effects.

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.

Surgical excision of the breast giant fibroadenoma under regional anesthesia by Pecs II and internal intercostal plane block: a case report and brief technical description: a case report

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.