Efficacy of Pectoral Nerve Block Type II for Breast-Conserving Surgery and Sentinel Lymph Node Biopsy: A Prospective Randomized Controlled Study

The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial

BACKGROUND

Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy.

METHODS

A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7.

RESULTS

Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point.

CONCLUSIONS

There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery

Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.

The Pectoral (PECS) Regional Block: A Scoping Review

Among the various surgical procedures, breast surgeries rank as a frequently conducted procedure. Interfacial blocks such as the Pectoral (PECS) block became possible with the currently available knowledge on innervations and ultrasound. Interfacial blocks target the deep fascial planes, which are potential spaces for injecting local anesthetics. The Pectoral I (PECS I) consists of the injection of local anesthetics in the plane between the pectoralis major and minor muscles. The PECS II block, a modified version of the block, is achieved by adding another, deeper injection in the plane between the pectoralis minor and the serratus anterior muscle. We conducted a scoping review using Arkesy and O'Malley's framework, as described by Levac. We identified our research question as the uses of the PECS regional block technique with the choice of local anesthetics, including adjuncts, and its effectiveness in intraoperative and postoperative analgesia in the first 24 hours and incidence of postoperative nausea and vomiting. Subsequently, we identified the relevant studies that met our inclusion criteria and charted the data. Lastly, we summarized and reported the results. The PECS block was used in various breast surgeries, among which radical mastectomies with/without lymph node dissection were the most common. It was found that the PECS block reduced intraoperative opioid consumption in 60% and 24-hour postoperative opioid consumption in 93.3% of the included papers. Various local anesthetics were used such as ropivacaine, bupivacaine, and levobupivacaine. Ultrasound-guided interfacial plane blocks, such as the PECS block, are a recent development in regional anesthesia that offers analgesia for patients undergoing breast surgeries. The authors conclude that PECS block can provide a decrease in intraoperative and postoperative opioid consumption, a decrease in the incidence of nausea and vomiting, and can lead to overall patient satisfaction in terms of lower pain scores compared to systemic analgesia.

The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery-a prospective, randomized, controlled, and triple-blinded trial

BACKGROUND

Classic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery.

METHODS

In a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS).

DISCUSSION

This prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery.

TRIAL REGISTRATION

www.clinicaltrialsregister.eu ; EudraCT Nr: 2021-005452-11; Lukas Gasteiger MD, November 18, 2021.

Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study

Introduction

Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients.

Materials and methods

Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups.

Results

A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively.

Conclusion

OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Less use of rescue morphine when a combined PSP/IPP-block is used for postoperative analgesia in breast cancer surgery: A randomised controlled trial

BACKGROUND

Surgery for breast cancer is common, and intravenous opioids are often used to control postoperative pain. Recently, pectoralis-2 (PECS-2) block has emerged as a promising regional anaesthetic alternative. With nomenclature recently proposed, this block is termed combined PSP/IPP-block (pectoserratus plane block/interpectoral plane block).

OBJECTIVE

We aimed to compare the need for postoperative rescue morphine between the intervention group that received a pre-operative combined PSP/IPP-block and a control group that received peri-operative long-acting opioids for postoperative analgesia.

DESIGN

A randomised controlled study.

SETTING

Operating theatres of two Swedish hospitals. The patients were recruited between May 2017 and October 2020.

PATIENTS

Among the 199 women scheduled to undergo breast cancer surgery (sector resection or radical mastectomy) who were enrolled in the study, 185 were available for follow up.

INTERVENTION

All patients received general anaesthesia. The intervention group received a combined PSP/IPP-block before surgery. The control group received intravenous morphine 30 min before emergence from anaesthesia.

MAIN OUTCOME MEASURE

The primary endpoint was the cumulative need for intravenous rescue morphine to reach a predefined level of pain control (visual analogue scale score <40 mm) during the first 48 h after surgery.

RESULTS

Data from 92 and 93 patients in the intervention and control groups, respectively, were analysed. The amount of rescue morphine administered in the 48 h after surgery was significantly lower in the intervention group than in the control group (median: 2.25 vs 3.0 mg, P  = 0.021). The first measured pain score was lower in the intervention group than in the control group (35 vs. 40 mm, P  = 0.035). There was no significant difference in the incidence of nausea between the groups (8.7 vs. 12.9%, P  = 0.357).

CONCLUSION

The use of a combined PSP/IPP-block block before breast cancer surgery reduces the need for postoperative rescue morphine, even when compared with the use of intra-operative morphine.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03117894.

Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study

Background and Aims

Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery.

Material and Methods

This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block.

Results

The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable.

Conclusion

Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.

Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study

INTRODUCTION

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia.

MATERIAL AND METHODS

A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII).

RESULTS

Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar.

CONCLUSION

This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature

Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Analgesic Efficacies of Intraoperative Pectoralis Nerve II Block under Direct Vision in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: A Prospective, Randomized Controlled Study

This prospective, randomized study aimed to evaluate the efficacy of an intraoperative pectoralis nerve II block (PECS II block) under direct vision in the reduction of fentanyl consumption during postoperative 24 h in patients undergoing robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) using direct-to-implant (DTI) or tissue expander (TE). Thirty patients scheduled for RNSM with IBR were randomly allocated to the PECS (n = 15) or control (n = 15) groups. The PECS II block was applied under direct vision after RNSM. The primary outcome was the cumulative dose of fentanyl consumption. The secondary outcomes were pain intensity using a numerical rating scale (NRS) at rest and acting during the postoperative 24 h. The cumulative dose of fentanyl at 24 h was significantly lower in the PECS group than in the control group (p = 0.011). Patients in the PECS group showed significantly lower NRS scores during the first postoperative 2 h compared to those in the control group in both resting and acting pain (p < 0.05). An intraoperative PECS II block under direct vision can reduce opioid consumption during the postoperative 24 h and provide effective analgesia in patients undergoing RNSM with IBR using DTI or TE.

Randomized controlled trial to study the efficacy and safety of ultrasound-guided pectoral nerve block for superficial breast surgeries

BACKGROUND

Our study aimed to compare pectoral nerve (PEC) block with local anesthetic (LA) infiltration for providing analgesia in superficial breast surgeries.

MATERIALS AND METHODS

This prospective comparative randomized study included seventy American Society of Anesthesiologists I and II female patients undergoing excision of fibroadenoma. In Group 1, the LA mixture was infiltrated in the desired planes. In Group 2, PEC I and PEC II blocks were performed under ultrasound guidance. Patients were observed at regular time intervals for pain scores, time to first analgesic request, and the number of patients requiring rescue analgesia with the cumulative analgesic requirement, hemodynamic changes, and any adverse events.

RESULTS

The patients were comparable in demographic profile, duration of anesthesia, and hemodynamic parameters. NRS scores at all times after extubation were significantly lower in Group 2 as compared to Group 1 (P < 0.0001). All patients in Group 1 required additional analgesia, while only two in Group 2 received rescue analgesia (P < 0.0001). The time to first analgesic request was significantly longer in Group 1 as compared to group 2 (9.5 + 0.70 h vs. 1.35 + 0.83 h) (P < 0.0001). The cumulative requirement of tramadol in Group 1 (96.88 ± 16.45 mg) was significantly higher than in Group 2 (6.47 ± 26.38 mg) (P < 0.0001). No adverse event was reported in either group.

CONCLUSION

PEC block is a useful method for achieving effective and long-lasting analgesia. It is an efficient and safe alternative to LA infiltration in patients undergoing fibroadenoma excision.

PEC block versus local anesthetic infiltration in breast implant augmentation surgery: a retrospective study

INTRODUCTION

Pectoral plane (PEC) blocks are routinely used in analgesia for patients undergoing dual-plane breast augmentation with implants. Local anesthetic infiltration (LAI) is a simple alternative technique with the same aim. We evaluated both techniques.

MM

In this single-center retrospective study, patients received PEC block (ropivacaine 0.2%, 10 ml PEC I, 20 ml PEC II) or LAI. The primary outcome measure was pain, according to the visual analog scale (VAS), at 24h post-surgery. Secondary outcomes included the measure of pain at 1, 2, 6, and 12 hours post-surgery, total opioid consumption at 24h, and opioid side effects.

RESULTS

81 were finally recruited: 37 in the PEC group and 44 in the LAI group. Patient characteristics were comparable between the two groups. At 24h post-surgery, the LAI group showed a decrease in pain, with a VAS score of 0.7 vs 1.5 in the PEC group (p = 0.007). There was no difference in VAS between the two groups at 1, 2, 6, or 12 hours post-surgery. The duration of anesthesia was increased in the PEC group with 153 minutes vs 120 minutes in the LAI group (p < 0.001). There was no difference in rescue morphine consumption between the two groups.

CONCLUSIONS

We found that LAI had a superior analgesic effect at 24h after surgery for dual-plane breast implant augmentation compared with PEC block. These findings are a good indication that the LAI technique is at least as effective as PEC block while being safe, fast, and easy to use.

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.

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.

Systematic review and meta-analysis of the efficacy of general anesthesia combined with a thoracic nerve block in modified breast cancer surgery

BACKGROUND

Breast cancer is a malignant tumor disease that poses a significant threat to women's health. In recent years, the incidence of breast cancer in China has been increasing. This report aims to explore the effects of general anesthesia combined with a thoracic nerve block in modified breast cancer surgery.

METHODS

A computer-based search of PubMed, Web of Science, Embase, and the Cochrane Library was performed to identify randomized controlled studies on breast cancer, general anesthesia combined with a thoracic nerve block, modified breast cancer surgery, and other breast cancer treatments. Further search criteria included postoperative pain score, postoperative morphine equivalents given 24 hours after surgery, and operation duration. After an initial selection process, the studies were evaluated using the Jadad scale and the Cochrane Handbook for Systematic Reviews of Interventions to assess their suitability for inclusion in the subsequent meta-analysis of the experimental data, which was carried out using RevMan 5.3.

RESULTS

A total of 8 studies comprising a total of 624 patients were selected for inclusion in this report. According to the meta-analysis, the analytical structure of the thoracic nerve group and the control group had a mean difference (MD) of -1.27 [95% confidence interval (CI): -1.68 to -0.86], the structure of the statistical test was Z=6.08 (P<0.00001), the MD of the total analysis structure of morphine equivalents was -2.71 (95% CI: -4.98 to -0.44), and the statistical test structure was Z=2.34 (P=0.02).

DISCUSSION

General anesthesia combined with a thoracic nerve block in breast cancer surgery may effectively improve postoperative pain in patients and reduce the need for analgesic drugs. However, the outcome indicators included in this study are not sufficient. It is necessary to increase both the sample size and the number of outcome indicators to provide further theoretical evidence for the subsequent application of thoracic nerve block in modified breast cancer surgery.

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018

BACKGROUND

Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery.

METHODS

We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression.

RESULTS

Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use.

CONCLUSIONS

We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.

Pectoral nerve blocks for breast surgery: A meta-analysis

BACKGROUND

Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery.

OBJECTIVE

The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery.

DESIGN

We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment.

DATA SOURCES

The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched.

ELIGIBILITY CRITERIA

All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included.

RESULTS

A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference -1.14, 95% confidence interval (CI), -2.1 to -0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference -1.79, 95% CI, -3.5 to -0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference -0.83, 95% CI, -1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference -0.18, 95% CI, -1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference -0.56, 95% CI, -1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported.

CONCLUSION

There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted.

PROTOCOL REGISTRATION

CRD42019126733.

Effect of Isolated Serum from Breast Cancer Patients with Pectoral Nerves Block on Breast Cancer Cell Line (MDA-MB-231) Apoptosis Index

Background

Breast cancer (BC) is the most frequent cause of cancer death in women. The thoracic pectoral nerve (PECS) block has been described as the gold standard analgesic modality for BC surgery. It has been previously reported that PECS is associated with decreased BC recurrence post-mastectomy. Although several anesthetic drugs and techniques are used in surgical oncology, their effects on the behavior of cancer cells are yet to be known and the key question of whether the anesthetic technique affects cancer outcome remains unresolved.

Objectives

Since anesthetic drugs and techniques and post-operative pain may affect BC recurrence, this study aimed to determine whether the anesthetic choice and technique, PECS II block, affects in vitro apoptosis of the MDA-MB-231 BC cell line.

Methods

Twenty-two female BC patients, 20 to 75-years-old, with the same pathologic grades were included in this study. The patients were randomly divided into two groups. The first group received propofol general anesthesia (PGA) associated with PECS and the second group received standard PGA. Blood was sampled pre and post-operation from all patients. The sera were isolated and then exposed to the MDA-MB-231 human BC cell line. The mean percentage of apoptosis indices was analyzed by flow cytometry using Annexin V-fluorescein isothiocyanate 24 hours after treatment with patients' sera.

Results

A significant decrease was seen in the mean viability percentage of BC cell line in the PECS group, besides a significant increase in the mean percentage of necrosis and late apoptosis indices compared to the control group after exposure to sera collected from patients post-operation. Intra-group analysis of the control group showed that the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of necrosis and late apoptosis index compared to pre-operation sera exposure. In the PECS group, the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of cell viability and late apoptosis index compared to pre-operation sera exposure.

Conclusions

In conclusion, anesthesia and BC surgery may induce apoptosis indices in the MDA-MB-231 human BC cell line. We also found that sera collected from PECS II block patients with BC could induce more apoptosis in the MDA-MB-231 cell line compared to collected sera from systemic analgesia alone after BC surgery.

Pretreatment with Pectoral Nerve Block II Is Effective for Reducing Pain in Patients Undergoing Thoracoscopic Lobectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Although video-assisted thoracoscopy has a smaller incision than traditional surgery, the postoperative pain is still severe. Ultrasound-guided pectoral nerve block (PECS) II is a new technique that can reduce pain in patients, and it had not been reported in the analgesia after thoracoscopic lobectomy.

Methods

40 patients scheduled for thoracoscopic lobectomy were randomly divided into two groups. Patients in the PECS II group received 0.5% ropivacaine 25 ml before the general anesthesia, while patients in the placebo group received 0.9% saline. Thirty minutes after the block was performed, a pin-prick test was used to analyze the sense of pain of T2-T6 segments. The primary endpoint was the total consumption of fentanyl. Data were collected in the postanesthesia care unit (PACU) and in the ward within 24 hours after operation.

Results

The total consumption of fentanyl and the consumption of fentanyl in the intravenous analgesia pump within 24 hours after the operation were significantly lower in the PECS II group compared to the placebo group (p < 0.05). The implementation rate of rescue analgesia during operation and in PACU in the PECS II group was significantly lower than that in the placebo group (p < 0.05). The numerical rating scale (NRS) in 1 and 4 h after operation was lower in the PECS II group (p < 0.05). Mean arterial pressure (MAP) and heart rate (HR) of the PECS II group at chest entering (T1) were significantly lower than those in the placebo group (p < 0.05).

Conclusion

Preconditioning of PECS II can stabilize the intraoperative circulation and significantly reduce pain and the consumption of opioids after operation.

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.

Synergistic Effects of Dexamethasone and Dexmedetomidine in Extending the Effects of Pectoral I and Pectoral II Blocks for Postoperative Analgesia Following Total Mastectomy with Lymph Node Dissection

Regional anesthesia is an important aspect of the overall anesthetic plan for patients. It has the potential to offer superior benefits compared to opioid-based treatment and is an important component of Enhanced Recovery after Surgery (ERAS) protocols. The use of the pectoral type I (PECS I) and pectoral type II blocks (PECS II) has been shown to reduce postoperative pain and opioid consumption in patients undergoing complete mastectomy and breast surgery. We describe the use of dexamethasone and dexmedetomidine to prolong the analgesic effects of these regional blocks in a patient undergoing total mastectomy with lymph node dissection.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial

PURPOSE

Although breast-conserving surgery-axillary dissection (BCS-AD) is a minimally invasive surgery, patients may suffer from moderate-to-severe pain. Several regional techniques can be used for pain control. The type II pectoral nerve block (PECS II) and the rhomboid intercostal block (RIB) are interfascial plane blocks that have been reported to provide effective analgesia after breast surgery. This study aims to compare the analgesic efficacy of the PECS II block and the RIB after breast surgery.

PATIENTS AND METHODS

Ninety female patients aged 18 to 65 years with American Society of Anesthesiologists (ASA) classes I and II physical status who underwent unilateral BCS-AD surgery were included. Patients were divided into three groups (n = 30 in each): the PECS II group, the RIB group, or the control group. PECS II block and RIB were performed with 30 mL 0.25% bupivacaine. Ibuprofen 400 mg IV 3 × 1 was given in the postoperative period. A patient control analgesia device included a dose of 10 µg/mL fentanyl, which was prepared and connected to the patients.

RESULTS

There were no statistical differences between groups in terms of demographical data. Postoperative fentanyl consumption was significantly lower in the PECS II and RIB groups than the control group. The need for rescue analgesia use was significantly higher in the control group than the other groups. At all times, visual analog scale scores were significantly lower in the PECS II and RIB groups than the control group.

CONCLUSIONS

The PECS II block and the RIB provide similar effective analgesia after BCS-AD.

Effects of Lean Thinking and Emerging Technologies on Breast Cancer Patients' Therapeutic Process During COVID-19 Pandemic: A Case-Control Matched Study

Introduction: The advent of the COVID-19 pandemic has led to the sudden disruption of routine medical care, and the subsequent reorganization of hospital structures and therapeutic algorithms, aiming at protecting patients and health professionals. This was inevitably bound to affect our Breast Unit, dilating both pre- and post-operative times. The aim of this study was to evaluate the effect on patients' flow of organizational and logistic changes (key interventions) based on lean thinking implemented after the COVID-19 outbreak.

Materials and Methods: Clinical and demographic data were retrospectively collected from patients undergoing sentinel lymph node biopsy for breast cancer at the Verona University Hospital from January 2018 to June 2020. Patients enrolled (n = 341) were divided into two groups according to date of admission: before (Group A; n = 294) and after (Group B; n = 47) the implementation of key interventions. Each case in Group B was subsequently matched 1:1 by means of case-control matching with cases from Group A for age, comorbidities, and type of surgery (Subgroup A1; N = 47). Pre-admission time (T0) and length of stay (T1) were compared between the three groups.

Results: Median T0 was 312 h, whereas median T1 was 24 h. Patients in Group B had a higher frequency of comorbidities (57.4 vs. 25.2%, p = 0.001) and underwent mastectomy more often than patients in Group A (61.7 vs. 36.7%, p = 0.001). Both median T0 and T1 were higher in group B than in group A (384 vs. 300 h, p = 0.001, 48 vs. 24 h, p = 0.001, respectively). Median T0 and T1 did not significantly differ between Group B and Subgroup A1 (all p > 0.05).

Conclusions: Lean thinking and new technologies could prove useful to the optimization of preoperative and postoperative times during the current pandemic, minimizing healthcare personnel and patients' exposure to SARS-CoV-2, and promoting a rational use of limited resources, while complying with oncological principles.

Mode of Anesthesia and Quality of Recovery After Breast Surgery: A Case Series of 100 Patients

PURPOSE

Regional anesthesia techniques may improve patient recovery beyond treating postoperative pain alone and may facilitate patients in their return to functional, psychological as well as emotional baselines. We hypothesized that the quality of recovery (QoR) experienced by patients following breast surgery was associated with the type of anesthesia received as well as the use of a regional anesthesia technique during surgery.

METHODS

We performed a single-center prospective, observational cohort study of patients undergoing elective breast procedures (both cancer and non-cancer surgery).

RESULTS

 One hundred patients completed baseline QoR-15 questionnaires prior to surgery, of which 96 also completed QoR-15 questionnaires on postoperative day 1. The median (IQR) QoR-15 score at baseline was 133 (124-141), decreasing to 121 (106.75-136.25) on postoperative day 1. In multivariable linear regression analysis, paravertebral blocks (PVB) were associated with a 16.7 point higher overall QoR-15 score on postoperative day 1 compared to no block (95% Confidence Interval [CI]: 7.7-25.8, p<0.001); while the use of combination blocks was associated with a 21.8 point higher postoperative QoR-15 score compared to no block (95% CI: 12.8-30.8, p<0.001). PVB and combination blocks were further associated with better postoperative pain, physical comfort, physical independence and emotional state scores, compared with no block. The use of total intravenous anesthetic was not associated with differences in postoperative QoR-15 score versus volatile anesthetic, after covariate adjustment.

CONCLUSION

Breast surgery patients receiving PVB or a combination of regional blocks during surgery have higher postoperative QoR-15 scores, after adjustment for other factors.

Randomized controlled trial comparing the efficacy of pectoral nerve block with general anesthesia alone in patients undergoing unilateral mastectomy

This study was conducted to evaluate the efficacy of pectoral nerve block for post-operative analgesia in breast surgery patients. This double blinded, randomized controlled trial was conducted after Clinical Trials Registry-India registration. Sixty ASA grade I-II female patients undergoing unilateral modified radical mastectomy under general anesthesia, were recruited pre-operatively in two groups. PECS group (n  =  29) was given ipsilateral pectoral nerve block I & II while the CONTROL group (n  =  29) directly proceeded to surgery. Our primary outcome was comparison of immediate post-operative pain scores at rest and movement. The secondary outcomes were post-operative pain scores at 2, 4, 6, 12, 18, and 24 h, total intraoperative fentanyl consumption, time to rescue analgesia, post-operative nausea vomiting, and complications, if any. Categorical data was analyzed by using the chi-squared test or Fishers Exact test. Comparison of pain scores was analyzed by using the Independent sample t test. The immediate post-operative pain scores in two groups were comparable. The pain scores were also comparable at 4, 6, 12, and 24 h; but statistically significantly lower in PECS group at 2 and 18 h. The total intraoperative fentanyl consumption was also reduced in PECS group (P = 0.009). Only 9 patients in PECS group (796.5 min) as compared to 22 patients in CONTROL group (387.7 min) required rescue analgesia (P  =  0.001). Pectoral nerve block benefits patients undergoing mastectomy by achieving similar post-operative pain scores with decreased consumption of intraoperative and post-operative opioids. Registration. Clinical Trials Registry of India, (CTRI/2017/04/008289). ctri.nic.in.

The efficacy of ultrasound-guided erector spinae plane block after mastectomy and immediate breast reconstruction with a tissue expander: a randomized clinical trial

Background

We aimed to investigate the analgesic efficacy of an erector spinae plane block (ESPB) in immediate breast reconstruction (IBR) with a tissue expander.

Methods

Adult women undergoing IBR with a tissue expander after mastectomy were randomly assigned to either intravenous patient-controlled analgesia (IV-PCA) alone (group P) or IV-PCA plus ESPB (group E). The primary outcome was the total amount of opioid consumption during 24 hours postoperatively between the two groups. Secondary outcomes were patient satisfaction, pain score at rest and on shoulder movement using numerical rating scale, incidences of postoperative nausea and vomiting (PONV), and a short form of the brief pain inventory (BPI-SF) at 3 and 6 months after surgery between the groups.

Results

Fifty eight patients completed the study. At 24 hours postoperatively, total opioid consumption was significantly less in group E than in group P (285.0 ± 92.0, 95% confidence interval [CI] 250.1 to 320.0 vs. 223.2 ± 83.4, 95% CI 191.5 to 254.9, P = 0.005). Intraoperative and cumulative PCA fentanyl consumption at 3, 6, 9, and 24 hours were also less in group E than in group P (P = 0.004, P = 0.048, P = 0.020, P = 0.036, and P < 0.001, respectively). Patient satisfaction was higher in group E (6.9 ± 1.8 vs. 7.8 ± 1.4, P = 0.042). The incidences of PONV was similar.

Conclusions

The ESPB decreased postoperative opioid consumption and increased patient satisfaction without significant complications after IBR with a tissue expander after mastectomy.

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Establishing a Technique for Pectoral II-Block Catheter Insertion with Ultrasound Guidance: A Randomized Controlled Trial

Purpose

To assess the efficacy and safety of a modified technique for ultrasound-guided pectoral II block for postoperative pain control after mastectomy.

Methods

In this randomized controlled trial, patients were randomly allocated into two groups (40 patients each). Group I patients were subjected to ultrasound-guided pectoral II block with injection of 10 mL lidocaine 1% as a dissecting solution before attempting catheter insertion, while group II patients underwent the standard procedure without a dissecting solution. Measured outcomes included catheter visibility, pain, patient satisfaction, performance time, and complications.

Results

Compared with group II, group I had significantly lower median catheter-visibility scores, shorter block performance time, and fewer insertion attempts. Group I had a nonsignificantly higher rate of complications than group II.

Conclusion

The modified technique facilitated the procedure, shortened the catheter-insertion time, and showed higher patient satisfaction. However, it was associated with lower catheter visibility on ultrasonography. Further studies are required to confirm the present findings and assess the safety of the modified technique.

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.

The emerging role of pectoral nerve block (PECS block) in breast surgery: A case-matched analysis

To evaluate the benefits of pectoral nerve block (PECS block) in breast cancer surgery, we compared outcomes of 100 patients receiving PECS vs 107 without PECS. Intraoperative use of fentanyl (P < .001) acetaminophen (P = .02), morphine (P < .01), and nonsteroidal anti-inflammatory drugs (NSAIDS) (P < .01) was lower in the PECS group. Occurrence of postoperative nausea and vomiting (PONV) was lower in the PECS group (P = .04). On postoperative day 1, the use of acetaminophen (P = .23), morphine (P = .83), and NSAIDS (P = .4) did not differ. Twenty-one patients received surgery with PECS block plus sedation alone. PECS block can reduce intraoperative use of opioids and analgesic drugs, and is associated with reduced occurrence of PONV. Selected patients can receive breast-conserving surgery with PECS plus sedation, avoiding general anesthesia.

Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: A systematic review and meta-analysis

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women, and more than half of breast surgery patients experience severe acute postoperative pain. This meta-analysis is designed to examine the clinical analgesic efficacy of Pecs block in patients undergoing breast cancer surgery.

METHODS

An electronic literature search of the Library of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted to collect randomized controlled trials (RCTs) from inception to November 2018. These RCTs compared the effect of Pecs block in combination with general anesthesia (GA) to GA alone in mastectomy surgery. Pain scores, intraoperative and postoperative opioid consumption, time to first request for analgesia, and incidence of postoperative nausea and vomiting were analyzed.

RESULTS

Thirteen RCTs with 940 patients were included in our analysis. The use of Pecs block significantly reduced pain scores in the postanesthesia care unit (weighted mean difference [WMD] = -1.90; 95% confidence interval [CI], -2.90 to -0.91; P < .001) and at 24 hours after surgery (WMD = -1.01; 95% CI, -1.64 to -0.38; P < .001). Moreover, Pecs block decreased postoperative opioid consumption in the postanesthesia care unit (WMD = -1.93; 95% CI, -3.51 to -0.34; P = .017) and at 24 hours (WMD = -11.88; 95% CI, -15.50 to -8.26; P < .001). Pecs block also reduced intraoperative opioid consumption (WMD = -85.52; 95% CI, -121.47 to -49.56; P < .001) and prolonged the time to first analgesic request (WMD = 296.69; 95% CI, 139.91-453.48; P < .001). There were no statistically significant differences in postoperative nausea and vomiting and block-related complications.

CONCLUSIONS

Adding Pecs block to GA procedure results in lower pain scores, less opioid consumption and longer time to first analgesic request in patients undergoing breast cancer surgery compared to GA procedure alone.

What Can Breast and Plastic Surgeons Do to Help Fight the Opioid Crisis: The Interpectoral Block for Pain Control Following Aesthetic and Reconstructive Breast Surgery

With the heightened awareness of the dangers of opioid administration, the importance of providing effective non-opioid postoperative pain management is evident. Regional analgesia for breast surgery has been described, but it is unclear how widely it is utilized. The authors describe a simple block performed during ablative, aesthetic, and reconstructive breast surgery to improve postoperative pain control and significantly decrease the need for postoperative pain medications. The interpectoral (PECS I) block covers the lateral and medial pectoral nerves and can be administered by the anesthesiologist under ultrasound guidance after induction of general anesthesia, or by the surgeon under direct vision, using a blunt cannula, at the time of surgery. The authors have been practicing this technique in every patient undergoing aesthetic, ablative, and reconstructive breast surgery in the last 4 years. In approximately 350 patients, none received opioids after discharge, which was either same day or the following day. The authors provide a brief review of the literature and a detailed description of the technique along with a video demonstrating the procedures. Intraoperative pectoral block is a simple and effective technique for decreasing postoperative pain and analgesic requirements and could be widely adopted as a standard of care in breast surgery.

Pectoral Nerve (PECs) block for postoperative analgesia-a systematic review and meta-analysis with trial sequential analysis

BACKGROUND AND OBJECTIVE

Pectoral Nerve (PECs) block is a fascial plane block first described by Blanco et al. for postoperative analgesia in breast surgery. The procedure is now widely used, and several small clinical trials have been published and reported favorably on the analgesic efficacy of PECs block. In this systematic review and meta-analysis, we will summarize the current evidence on the efficacy of PECs block.

METHODS

We identified and analyzed 19 randomized control trials from PubMed, Central, EMBASE, CINAHL, Web of Science citation index, US clinical trials register and Google Scholar. The primary outcome was 24-hour opioid requirement, and secondary outcomes included pain scores, postoperative nausea and vomiting and other complications.

RESULTS

Compared to systemic analgesia, PECs block was associated with reduced 24 hours opioid requirement [mean difference (MD) = -10.66 mg], lower pain score [9-12 hours postoperatively: MD = -1.18; 24 hours postoperatively: MD = -0.79] and less frequent PONV [risk ratio (RR) = 0.37, numbers needed to treat (NNT) = 5]. While the failure rate of PECs block was not well defined, several studies reported significant intraoperative opioid requirement despite PECs block. Lastly, trial sequential analysis indicated that no more clinical trials are needed to demonstrate the opioid sparing effect of PECs block.

CONCLUSION

When compared to general anesthesia with systemic opioids, PECs block was associated with significantly better perioperative pain control. There are currently insufficient data on the complication and failure rate of PECs block in clinical practice.

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management-American Society of Breast Surgeons Opioid/Pain Control Workgroup

INTRODUCTION

The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence.

METHODS

A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies.

RESULTS

A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns.

CONCLUSIONS

Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.

The role of pectoral nerve blocks in a day-case mastectomy service: A prospective cohort study

Background

It is now recognised that the majority of breast surgery can be safely undertaken as day case procedures. We aimed to evaluate the effect of pectoral nerve (Pecs2) blocks on recovery parameters and day case rates in patients undergoing mastectomy for breast cancer.

Methods

A prospective cohort study was performed in a single NHS Foundation trust between 1st April 2014 and 31st December 2016. Visual analogue scale (VAS) pain scores (0-10) at 4 and 8 h, episodes of post-operative nausea ± vomiting (PONV), opioid use and day case outcome were compared between Pecs2 and no Pecs2 groups.

Results

22 patients underwent general anaesthesia (GA) + Pecs2 block and 30 GA ± local anaesthetic infiltration.Mean pain scores were significantly lower in the Pecs2 (2.5) vs no Pecs2 (4.6) group at 4 h (p = 0.0132) and 8 h, Pecs2 (1.9) vs no Pecs2 (3.6) (p = 0.0038).Episodes of PONV requiring additional anti-emetic were lower and statistically significant in the Pecs2 group (2/22, 9%) than the no Pecs2 group (14/30, 46%), (p = 0.005).Additional opioid use was significantly lower in the Pecs2 group (4/22, 18%) than in the no Pecs2 group (14/30, 46%) (p = 0.0423).18 patients in the Pecs2 group were discharged the same day in contrast to just 3 patients in the no Pecs2 group. This was highly statistically significant (p = 0.0001).

Conclusions

Pecs2 blocks can significantly reduce post-operative pain, nausea and vomiting in patients undergoing mastectomy. Their use can enable units to achieve high day-case mastectomy rates.

Remifentanil-Sparing Effect of Pectoral Nerve Block Type II in Breast Surgery under Surgical Pleth Index-Guided Analgesia during Total Intravenous Anesthesia

The pectoral nerve block type II (Pecs II block) can provide adequate perioperative analgesia in breast surgery. The surgical pleth index (SPI) is used to monitor the nociception balance using pulse oximetry. We investigated the remifentanil-sparing effect of Pecs II block under SPI guided analgesia during total intravenous anesthesia (TIVA). Thirty-nine patients undergoing breast surgery under remifentanil-propofol anesthesia were randomly assigned to the intervention (Pecs group, n = 20) or control group (n = 19). Remifentanil and propofol concentrations were adjusted to maintain an SPI of 20–50 and a bispectral index of 40–60, respectively. The Pecs group received an ultrasound-guided Pecs II block preoperatively using 30 mL of 0.5% ropivacaine. Total infused remifentanil during the surgery was significantly less in the Pecs group than in the control group (6.8 ± 2.2 μg/kg/h vs. 10.1 ± 3.7 μg/kg/h, p = 0.001). Pain scores on arrival at the postanesthetic care unit (PACU) (3 (2–5) vs. 5 (4–7)) and the rescue analgesic requirement in the PACU (9 vs. 2) was significantly lower in the Pecs group than in the control group. In conclusion, Pecs II block was able to reduce the intraoperative remifentanil consumption by approximately 30% and improve the postoperative pain in PACU in patients undergoing breast surgery under SPI-guided analgesia during TIVA.

Combined ultrasound-guided Pecs II block and general anesthesia are effective for reducing pain from modified radical mastectomy

Purpose: Combined regional and general anesthesia are often used for the management of breast cancer surgery. Thoracic spinal block, thoracic epidural block, thoracic paravertebral block, and multiple intercostal nerve blocks are the regional anesthesia techniques which have been used in breast surgery, but some anesthesiologists are not comfortable because of the complication and side effects. In 2012, Blanco et al introduced pectoralis nerve (Pecs) II block or modified Pecs block as a novel approach to breast surgery. This study aims to determine the effectiveness of combined ultrasound-guided Pecs II block and general anesthesia for reducing intra- and postoperative pain from modified radical mastectomy.

Patients and methods: Fifty patients undergoing modified radical mastectomy with general anesthesia were divided into two groups randomly (n=25), to either Pecs (P) group or control (C) group. Ultrasound-guided Pecs II block was done with 0.25% bupivacaine (P group) or 0.9% NaCl (C group). Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid consumption, postoperative visual analog scale (VAS) score, and postoperative opioid consumption were measured.

Results: Intraoperative opioid consumption was significantly lower in P group (P≤0.05). VAS score at 3, 6, 12, and 24 hrs postoperative were significantly lower in P group (P≤0.05). Twenty-four hours postoperative opioid consumption was significantly lower in P group (P≤0.05). There are no complications following Pecs block in both groups, including pneumothorax, vascular puncture, and hematoma.

Conclusion: Combined ultrasound-guided Pecs II block and general anesthesia are effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy. Ultrasound-guided Pecs II block is a relatively safe peripheral nerve block.

Is COMBIPECS the answer to perioperative analgesia for breast surgery? A double blinded randomized controlled trial

Background and Aims

Pecs block and its variations provides perioperative analgesia, reduce PONV and other opioid related side effects. We hypothesized that COMIBPES block in addition to general anaesthesia will provide better postoperative analgesia when compared to general anaesthesia alone in breast cancer surgery patients.

Methods

After obtaining permission from the institutional review board and registering the trial with Clinical Trials Registry of India (CTRI), we conducted a double blinded randomized controlled trial of 100 patients posted for elective breast surgery with axillary dissection. Patients were divided into two groups, P (Pecs block) and C (control). Intraoperative analgesia, postoperative analgesia, postoperative nausea vomiting (PONV) and shoulder mobility on first postoperative day (POD1) were noted. Primary outcomes were the pain scores measured by visual analog scale (VAS) and cumulative intravenous morphine consumption from patient controlled analgesia (PCA) pump at measurement intervals of 0, 1, 4, 8, 12 and 24 hours postoperatively.

Results

Intraoperatively, Group P patients did not require any additional analgesia, whereas all the patients in Group C required additional intraoperative morphine (mean, SD: 5.12, 2.63 mg, compared to nil in group P, P< 0.01). COMBIPECS block group had lower pain scores and PCA morphine requirements, less PONV and better shoulder mobility on POD1.

Conclusion

COMBIPECS block is a valuable addition to general anaesthesia for breast cancer surgery as it reduces pain and PONV while allowing better postoperative shoulder mobility.