1
|
Huh J, Lee N, Kim M, Choi H, Oh DY, Choi J, Hwang W. Comparison of Nefopam-Based Patient-Controlled Analgesia with Opioid-Based Patient-Controlled Analgesia for Postoperative Pain Management in Immediate Breast Reconstruction Surgery: A Randomized Controlled Trial. J Clin Med 2024; 13:3490. [PMID: 38930019 PMCID: PMC11204651 DOI: 10.3390/jcm13123490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Immediate breast reconstruction surgery (BRS) often leads to significant postoperative pain, necessitating effective analgesia. This study aimed to compare the analgesic efficacy of patient-controlled analgesia (PCA) containing nefopam with that of PCA containing opioids alone in patients undergoing BRS. Methods: A prospective, double-blind, randomized controlled trial was conducted on 120 patients undergoing immediate BRS after mastectomy. Patients were randomly allocated to receive PCA with fentanyl alone (Group F: fentanyl 10 mcg/kg), fentanyl and nefopam (Group FN: fentanyl 5 mcg/kg + nefopam 1 mg/kg), or nefopam alone (Group N: nefopam 2 mg/kg). Pain intensity (expressed in VASr and VASm), opioid consumption, and opioid-related complications were assessed. Results: PCA with nefopam, either alone or in combination with opioids, demonstrated non-inferior analgesic efficacy compared to PCA with fentanyl alone. At 24 h postoperatively, the VASr scores were 2.9 ± 1.0 in Group F, 3.1 ± 1.2 in Group FN, and 2.8 ± 0.9 in Group N (p = 0.501). At the same timepoint, the VASm scores were 4.1 ± 1.2 in Group F, 4.5 ± 1.5 in Group FN, and 3.8 ± 1.4 in Group N (p = 0.129). Significant differences among the three groups were observed at all timepoints except for PACU in terms of the total opioid consumption (p < 0.0001). However, there were no significant differences in opioid-related complications among the three groups. Conclusions: PCA with nefopam, whether alone or in combination with opioids, offers non-inferior analgesic efficacy compared to PCA with fentanyl alone in patients undergoing immediate BRS.
Collapse
Affiliation(s)
- Jaewon Huh
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.H.); (N.L.); (M.K.); (H.C.)
| | - Noori Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.H.); (N.L.); (M.K.); (H.C.)
| | - Minju Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.H.); (N.L.); (M.K.); (H.C.)
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.H.); (N.L.); (M.K.); (H.C.)
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.Y.O.); (J.C.)
| | - Jangyoun Choi
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.Y.O.); (J.C.)
| | - Wonjung Hwang
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.H.); (N.L.); (M.K.); (H.C.)
| |
Collapse
|
2
|
Vingan PS, Serafin J, Boe L, Zhang KK, Kim M, Sarraf L, Moo TA, Tadros AB, Allen R, Mehrara BJ, Tokita H, Nelson JA. Reducing Disparities: Regional Anesthesia Blocks for Mastectomy with Reconstruction Within Standardized Regional Anesthesia Pathways. Ann Surg Oncol 2024; 31:3684-3693. [PMID: 38388930 PMCID: PMC11267583 DOI: 10.1245/s10434-024-15094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Recent data suggest disparities in receipt of regional anesthesia prior to breast reconstruction. We aimed to understand factors associated with block receipt for mastectomy with immediate tissue expander (TE) reconstruction in a high-volume ambulatory surgery practice with standardized regional anesthesia pathways. PATIENTS AND METHODS Patients who underwent mastectomy with immediate TE reconstruction from 2017 to 2022 were included. All patients were considered eligible for and were offered preoperative nerve blocks as part of routine anesthesia care. Interpreters were used for non-English speaking patients. Patients who declined a block were compared with those who opted for the procedure. RESULTS Of 4213 patients who underwent mastectomy with immediate TE reconstruction, 91% accepted and 9% declined a nerve block. On univariate analyses, patients with the lowest rate of block refusal were white, non-Hispanic, English speakers, patients with commercial insurance, and patients undergoing bilateral reconstruction. The rate of block refusal went down from 12 in 2017 to 6% in 2022. Multivariable logistic regression demonstrated that older age (p = 0.011), Hispanic ethnicity (versus non-Hispanic; p = 0.049), Medicaid status (versus commercial insurance; p < 0.001), unilateral surgery (versus bilateral; p = 0.045), and reconstruction in earlier study years (versus 2022; 2017, p < 0.001; 2018, p < 0.001; 2019, p = 0.001; 2020, p = 0.006) were associated with block refusal. CONCLUSIONS An established preoperative regional anesthesia program with blocks offered to all patients undergoing mastectomy with TE reconstruction can result in decreased racial disparities. However, continued differences in age, ethnicity, and insurance status justify future efforts to enhance preoperative educational efforts that address patient hesitancies in these subpopulations.
Collapse
Affiliation(s)
- Perri S Vingan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanna Serafin
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lillian Boe
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin K Zhang
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Minji Kim
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Sarraf
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hanae Tokita
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
3
|
Kulturoglu G, Altinsoy S, Ergil J, Ozkan D, Ozguner Y. Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery. J Anesth 2024:10.1007/s00540-024-03351-3. [PMID: 38777932 DOI: 10.1007/s00540-024-03351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE The objective of this study was to examine the hypothesis that the opioid consumption of patients who receive a rhomboid intercostal block (RIB) or a pectoral nerve (PECS) block after unilateral modified radical mastectomy (MRM) surgery is less than that of patients who receive local anesthetic infiltration. METHODS Eighty-one female patients aged 18-70 years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30 ml of 0.25% bupivacaine on completion of the surgery, and the second received a PECS block with the same volume and concentration of local anesthetic. In the third (control) group, local infiltration was applied to the wound site with 30 ml of 0.25% bupivacaine at the end of the surgery. The patients' total tramadol consumption, quality of recovery (QoR), postoperative pain scores, and sleep quality were evaluated in the first 24 h postoperatively. RESULTS Both the RIB (58.3 ± 22.8 mg) and PECS (68.3 ± 21.2 mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6 mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6 h post-surgery. The lowest pain values were observed in the RIB group. The sleep quality of the patients in the RIB and PECS groups was better than that of the control group (p < 0.001). CONCLUSION Compared to local anesthetic infiltration, the RIB and PECS blocks applied as part of multimodal analgesia in MRM surgery reduced opioid consumption in the first 24 h and improved the quality of recovery in the early period.
Collapse
Affiliation(s)
- Gokcen Kulturoglu
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey.
| | - Savas Altinsoy
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Julide Ergil
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Derya Ozkan
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Yusuf Ozguner
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| |
Collapse
|
4
|
Mija D, Kehlet H, Joshi GP. Basic analgesic use in randomised trials assessing local and regional analgesic interventions for mastectomy: a critical appraisal and clinical implications. Br J Anaesth 2023; 131:921-924. [PMID: 37716888 DOI: 10.1016/j.bja.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 09/18/2023] Open
Abstract
Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n=82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate.
Collapse
Affiliation(s)
- Dan Mija
- Medical Graduate, Dallas, TX, USA
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
5
|
Anne Thamar Louis L, Fortin J, Roy CA, Brunet A, Aimé A. Body image interventions within breast cancer care: A systematic review and concept analysis. J Psychosoc Oncol 2023; 42:427-447. [PMID: 37609854 DOI: 10.1080/07347332.2023.2249879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
There needs to be a consensus regarding the definition of body image in oncology the literature. This lack of agreement leads to conflicting results in psychosocial interventions aimed to improve body image among breast cancer patients. Through an instrumentalist approach, this systematic review aims to analyze how body image as a concept is described and operationalized in breast cancer studies with the focus to enhance body image through psychosocial interventions. Databases were searched in October 2022 and updated in February 2023 to find empirical studies reporting psychosocial intervention targeting body image efficacy. The results from 24 studies show many similarities and differences between the definitions (e.g. characteristics) and questionnaires (e.g. Cronbach's alpha coefficient) used to evaluate this concept. Most definitions include thoughts, feelings, and behaviors related to body image. Finally, the psychosocial implications are discussed. This systematic review is registered on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022326393).
Collapse
Affiliation(s)
- Lunie Anne Thamar Louis
- Psychosocial Research Division, Research Center of the Douglas Mental Health University Institute, Verdun, Canada
| | - Justine Fortin
- Psychosocial Research Division, Research Center of the Douglas Mental Health University Institute, Verdun, Canada
- Department of Psychology, Université du Québec à Montréal, Montreal, Canada
| | - Carol-Anne Roy
- Psychosocial Research Division, Research Center of the Douglas Mental Health University Institute, Verdun, Canada
| | - Alain Brunet
- Psychosocial Research Division, Research Center of the Douglas Mental Health University Institute, Verdun, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Annie Aimé
- Department of Psychoeducation and Psychology, Université du Québec en Outaouais, Gatineau, Canada
| |
Collapse
|
6
|
Ameta N, Ramkiran S, Vivekanand D, Honwad M, Jaiswal A, Gupta MK. 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. J Anaesthesiol Clin Pharmacol 2023; 39:488-496. [PMID: 38025564 PMCID: PMC10661648 DOI: 10.4103/joacp.joacp_411_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 08/15/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Nihar Ameta
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Seshadri Ramkiran
- Department of Onco-Anesthesiology, HCG Cancer Centre, Kalinga Rao Road, Sampangiram Nagar, Bengaluru, India
| | | | - Manish Honwad
- Department of Cardiothoracic Anaesthesiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Alok Jaiswal
- Department of Anaesthesia, 150 General Hospital, C/O 99 APO, Meerut, Uttar Pradesh, India
| | - Manoj Kumar Gupta
- Station Health Organisation, Meerut Cantt, Meerut, Uttar Pradesh, India
| |
Collapse
|
7
|
Thalji SZ, Cortina CS, Guo MS, Kong AL. Postoperative Complications from Breast and Axillary Surgery. Surg Clin North Am 2022; 103:121-139. [DOI: 10.1016/j.suc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
8
|
Dyrberg DL, Bille C, Koudahl V, Gerke O, Sørensen JA, Thomsen JB. Evaluation of Breast Animation Deformity following Pre- and Subpectoral Direct-to-Implant Breast Reconstruction: A Randomized Controlled Trial. Arch Plast Surg 2022; 49:587-595. [PMID: 36159368 PMCID: PMC9507449 DOI: 10.1055/s-0042-1756337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/29/2022] [Indexed: 10/26/2022] Open
Abstract
Background The incidence of breast animation deformity (BAD) is reported to be substantial after direct-to-implant breast reconstruction with subpectoral implant placement. It has, however, never been examined if BAD can occur following prepectoral implant placement. Our primary aim was to compare the incidence and degree of BAD after direct-to-implant breast reconstruction using either subpectoral or prepectoral implant placement. Secondary aim of this study was to assess and compare the level of pain between sub- and prepectoral reconstructed women. Methods In this randomized controlled trial, patients were allocated to reconstruction by either subpectoral or prepectoral implant placement in accordance with the CONSORT guidelines. The degree of BAD was assessed by the "Nipple, Surrounding skin, Entire breast (NSE)" grading scale 12 months after surgery. The level of postoperative pain was assessed on a numerical pain rating scale. Results We found a significant difference in the degree of BAD favoring patients in the prepectoral group (23.8 vs. 100%, p < 0.0001; mean NSE grading scale score: 0.4 vs. 3.6, p < 0.0001). The subpectoral reconstructed group reported higher levels of pain on the three subsequent days after surgery. No significant difference in pain levels could be found at 3 months postoperatively. Conclusion The incidence and degree of BAD was significantly lower in women reconstructed by prepectoral direct-to-implant breast reconstruction. Unexpectedly, we found mild degrees of BAD in the prepectoral group. When assessing BAD, distortion can be challenging to discern from rippling.
Collapse
Affiliation(s)
- Diana L Dyrberg
- Department of Plastic Surgery, Odense University Hospital, Odense/Lillebaelt Hospital, Vejle, Denmark
| | - Camilla Bille
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Vibeke Koudahl
- Department of Plastic Surgery, Odense University Hospital, Odense/Lillebaelt Hospital, Vejle, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Jens A Sørensen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | - Jørn B Thomsen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| |
Collapse
|
9
|
Comparison of Outcomes Following Prepectoral and Subpectoral Implants for Breast Reconstruction: Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174223. [PMID: 36077760 PMCID: PMC9455042 DOI: 10.3390/cancers14174223] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Implant-based breast reconstruction following mastectomy helps to restore quality of life while aiming at providing optimal cosmetic outcomes. Both prepectoral (PP) and subpectoral (SP) breast implants are widely used to fulfill these objectives. It is, however, unclear which approach offers stronger postoperative benefits. (2) Methods: We performed a systematic review of the literature through PubMed, Cochrane Library, and ResearchGate, following the PRISMA guidelines. Quantitative analysis for postoperative pain as the primary outcome was conducted. Secondary outcomes included patient satisfaction and postoperative complications such as seroma, implant loss, skin necrosis, wound infection, and hematoma. (3) Results: Nine articles involving 1119 patients were retrieved. Our results suggested increased postoperative pain after SP implants and significantly higher rates of seroma following PP implants (p < 0.05). Patient satisfaction was found to be similar between the two groups; however, the heterogeneity of measurement tools did not allow us to pool these results. The rates of implant loss, skin necrosis, wound infection, and hematoma showed no significant differences between the two cohorts. (4) Conclusion: Our data suggest that both implant placements are safe and effective methods for breast reconstruction following mastectomy. However, homogeneity in outcome measurements would allow one to provide stronger statistical results.
Collapse
|
10
|
Shiraishi M, Sowa Y, Tsuge I, Shiraishi A, Inafuku N, Nakayama I, Morimoto N. Risk factors associated with chronic pain after mastectomy: a prospective study with a 5-year follow-up in Japan. Breast Cancer 2022; 29:1133-1139. [PMID: 36018439 DOI: 10.1007/s12282-022-01392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic pain is a major complication following breast surgery including breast reconstruction. We previously examined prospective patient-specific and medical/surgical factors that predict chronic pain a year after breast surgery in the Japanese population. Five-year survivorship is essential for breast cancer patients. This report is a 4-year follow-up study following the previous research. METHODS A follow-up observation study was performed 5 years after breast operations. The subjects were patients who underwent breast surgery, including tissue expander/implant (TE/implant), DIEP procedures and mastectomy only. Pain at 5 years was assessed using the Japanese Version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with chronic pain. RESULTS Questionnaires were completed by 132 subjects. No factor related to chronic pain was significantly related to the MPQ pain ratings. Among patient characteristics, a psychotic or neurological medical history was related to significantly lower visual analog scale (p = 0.02) and present pain index (p = 0.04) scores. A history of chemotherapy and/or hormone therapy was significantly associated with the frequency of use of pain medication postoperatively (p = 0.05) and effect on the social life of the patients (p = 0.02). CONCLUSIONS A psychotic or neurological history and a history of chemotherapy and/or hormone therapy were identified as risk factors for chronic pain after breast surgery, but the type of operation was not associated with chronic pain.
Collapse
Affiliation(s)
- Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan.,Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan. .,Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan.
| | - Itaru Tsuge
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Akiko Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan
| | - Naoki Inafuku
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 54 Shogoin Kawahara-cho, Sakyou-ku, Kyoto, 606-8507, Japan
| | - Ichiro Nakayama
- Department of Breast Surgery, Kyoto Miniren Chuo Hospital, Kyoto, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
11
|
Shiraishi M, Sowa Y, Kodama T, Numajiri T, Taguchi T, Amaya F. Localization of Chronic Pain in Postmastectomy Patients: A Prospective Comparison Between Patients With and Without Breast Reconstruction. Ann Plast Surg 2022; 88:490-495. [PMID: 35443265 DOI: 10.1097/sap.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND After breast surgery with or without immediate reconstruction, chronic pain can be a major problem for patients. However, few studies have examined the details of the sites of long-lasting postoperative pain. In this study, we specified the postoperative pain location after breast surgery, including reconstruction, to find ways to improve surgical procedures or provide effective pain relief. METHODS The subjects were 205 Japanese women undergoing mastectomy or breast reconstruction with a tissue expander (TE)/implant or a deep inferior epigastric perforator (DIEP) flap. Patients were asked whether they had pain in different parts of the body at 1 year after surgery. Differences were assessed by cross-tabulation and χ2 statistics. RESULTS Surveys were completed by 157 subjects. Deep inferior epigastric perforator flap cases had significantly more pain and TE/Imp cases had significantly less pain in the medial breast, upper breast, breast upper medial quadrant, and abdomen (P = 0.006, P = 0.006, P < 0.001, P < 0.001, respectively). In the neck area, pain in TE/Imp cases was significantly worse than that in all other patients (P = 0.025). There was no significant difference in chronic pain in any other body regions among the mastectomy only, TE/Imp, and DIEP flap groups. CONCLUSIONS The results of the present study revealed that the localization of prolonged postoperative pain after breast surgery differs depending on the surgical procedure. In DIEP flap reconstruction, there was a marked tendency for pain in the inner and upper chest and in the abdomen, whereas TE/IMP surgery resulted in pain around the neck of the affected side. These findings may help improve surgical methods and establish effective pain relief that focuses on the identified pain areas.
Collapse
Affiliation(s)
| | - Yoshihiro Sowa
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takuya Kodama
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Toshiaki Numajiri
- From the Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | | | - Fumimasa Amaya
- Pain Management and Palliative Care Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
12
|
Klinisches Update zu Phantomschmerz. Schmerz 2022; 37:195-214. [DOI: 10.1007/s00482-022-00629-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 10/18/2022]
|
13
|
BİCAK M, SALİK F. Comparison of the Analgesic Effects of Ultrasound Guided Pectoral Nerve Block Type II and Erector Spinae Plane Block in Breast Cancer Surgery. DICLE MEDICAL JOURNAL 2021. [DOI: 10.5798/dicletip.999785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
14
|
Chang PJ, Asher A, Smith SR. A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment. Cancers (Basel) 2021; 13:5191. [PMID: 34680339 PMCID: PMC8534110 DOI: 10.3390/cancers13205191] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/09/2021] [Accepted: 10/14/2021] [Indexed: 01/10/2023] Open
Abstract
Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.
Collapse
Affiliation(s)
- Philip J. Chang
- Department of Physical Medicine and Rehabilitation, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Arash Asher
- Department of Physical Medicine and Rehabilitation, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA;
| | - Sean R. Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48108, USA;
| |
Collapse
|
15
|
Abdel-Wahab AH, Gegres AK, Hamed R, Abdellatif MM. Fentanyl versus dexamethasone or both as adjuvants to bupivacaine in an ultrasound-guided paravertebral block in patients undergoing modified radical mastectomy: a randomized double-blind clinical study. Minerva Anestesiol 2021; 88:129-136. [PMID: 34527408 DOI: 10.23736/s0375-9393.21.15800-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to compare the effect of dexamethasone added to fentanyl and bupivacaine with the effect of either dexamethasone or fentanyl alone when combined with bupivacaine.in the thoracic paravertebral block (TPVB). METHODS Sixty female patients (aged 18-60 years), scheduled for modified radical mastectomy were enrolled. Patients received preoperative unilateral paravertebral block using 0.3ml/kg of 0.5% bupivacaine combined with 8 mg dexamethasone (Group I), 1 μg/kg fentanyl (Group II), or 8 mg dexamethasone + 1 μg/kg fentanyl (Group III). The study drugs were diluted with normal saline 0.9% up to 25ml volume. The primary outcome was the time to first postoperative analgesics request, Secondary outcomes were total analgesic consumption, verbal rating pain scale (VRS) over the first 24 hours postoperatively, hemodynamic parameters, and adverse effects. RESULTS The time to first analgesic request for intravenous (IV) nalbuphine was longer in group II (15.75 ± 0.9 h, P < 0.001) than group I (10.45±1.1 h, P < 0.001), while no patients requested it in group III (P < 0.001). The total analgesic consumption of IV nalbuphine was lower in group II (8.6 ± 3.5mg, P=0.04) than group I (11.3 ± 2.1mg), with a significant difference between group II and III (P < 0.001). From the 8th till the 24th hours postoperatively, patients in group III showed the significantly lowest median VAS scores, followed by patients in group II (P < 0.001) and lastly patients in group I. There were no significant adverse effects. CONCLUSIONS Dexamethasone and fentanyl Combination enhances the analgesic effect of bupivacaine in TPVB.
Collapse
Affiliation(s)
- Amani H Abdel-Wahab
- Anesthesia and Intensive Care Department, Faculty of medicine, Assiut University, Assiut, Egypt -
| | - Amonios K Gegres
- Anesthesia and Intensive Care Department, Faculty of medicine, Assiut University, Assiut, Egypt
| | - Rasha Hamed
- Anesthesia and Intensive Care Department, Faculty of medicine, Assiut University, Assiut, Egypt
| | - Mohamed M Abdellatif
- Anesthesia and Intensive Care Department, Faculty of medicine, Assiut University, Assiut, Egypt
| |
Collapse
|
16
|
Stewart JW, Ringqvist J, Wooldridge RD, Farr DE, Sunna M, Schulz C, Alexander JC, Minhajuddin A, Gasanova I, Joshi GP. Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies. Proc (Bayl Univ Med Cent) 2021; 34:571-574. [PMID: 34456475 DOI: 10.1080/08998280.2021.1919003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.
Collapse
Affiliation(s)
- Jesse W Stewart
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jenny Ringqvist
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rachel D Wooldridge
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deborah E Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mary Sunna
- Parkland Health and Hospital System, Dallas, Texas
| | - Cedar Schulz
- Parkland Health and Hospital System, Dallas, Texas
| | - John C Alexander
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Abu Minhajuddin
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Irina Gasanova
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
17
|
Abstract
Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.
Collapse
|
18
|
Nelson JA, Polanco TO, Shamsunder MG, Coriddi M, Matros E, Hicks MEV, Disa JJ, Mehrara BJ, Allen RJ, Dayan JH, Afonso A. Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes. Ann Surg Oncol 2021; 28:7823-7833. [PMID: 33959829 DOI: 10.1245/s10434-021-10023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/26/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction. METHODS We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q. RESULTS Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores. CONCLUSION System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.
Collapse
Affiliation(s)
- Jonas A Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Thais O Polanco
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meghana G Shamsunder
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph J Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak J Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph H Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | | |
Collapse
|
19
|
Tan PY, Anand SP, Chan DXH. Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211006419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete. Objectives: This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research. Methods: A PubMed search with the relevant keywords was done for articles published in the last 10 years. Results: The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy. Conclusions: PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.
Collapse
Affiliation(s)
- Pei Yu Tan
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore Health Services, Singapore
| | - Singh Prit Anand
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore Health Services, Singapore
| | - Diana Xin Hui Chan
- Division of Anaesthesiology and Perioperative Medicine, Department of Pain Medicine, Singapore General Hospital, Singapore Health Services, Singapore
| |
Collapse
|
20
|
Malik Z, Abbas M, Al Kury LT, Shah FA, Alam M, Khan AU, Nadeem H, Alghamdi S, Sahibzada MUK, Li S. Thiazolidine Derivatives Attenuate Carrageenan-Induced Inflammatory Pain in Mice. Drug Des Devel Ther 2021; 15:369-384. [PMID: 33574656 PMCID: PMC7871178 DOI: 10.2147/dddt.s281559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/18/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Peripheral inflammation leads to the development of persistent thermal hyperalgesia and mechanical allodynia associated with increased expression of interleukin-1β (IL-1β) in the spinal cord. The aim of the present study was to investigate the effects of thiazolidine derivatives, 1b ([2-(2-hydroxyphenyl)-1,3-thiazolidin-4-yl](morpholin-4-yl)methanone) and 1d (2-hydroxy-4-{[2-(2-hydroxyphenyl)-1,3-thiazolidine-4-carbonyl]amino}benzoic acid), on thermal hyperalgesia, mechanical allodynia and on IL-1β expression during carrageenan-induced inflammation in the spinal cord in mice. Inflammatory pain was induced by injecting 1% carrageenan into the right hind paw of the mice. METHODS The animals were administered thiazolidine derivatives, 1b and 1d (1 mg/kg, 3 mg/kg, or 10 mg/kg), intraperitoneally 30 minutes before carrageenan administration. The animals' behavior was evaluated by measuring thermal hyperalgesia, mechanical allodynia, and motor coordination. The IL-1β expression was measured by enzyme-linked immunosorbent assay. Acute and sub-acute toxicity studies were conducted to evaluate the toxicity profile of compounds. RESULTS Treatment with the thiazolidine derivative, 1b and 1d, attenuated carrageenan-induced thermal hyperalgesia and mechanical allodynia at doses of 1 mg/kg, 3 mg/kg, and 10 mg/kg. No motor coordination deficits were observed in animals. The compounds also reduced IL-1β expression in the spinal cord of mice. Acute and sub-acute toxicity studies revealed that both compounds were safe. CONCLUSION The compounds exhibit promising activity against inflammatory pain due to their ability to produce anti-hyperalgesic and anti-allodynic effects and to inhibit IL-1β expression in the spinal cord.
Collapse
Affiliation(s)
- Zulkifal Malik
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
- Faculty of Pharmacy, Capital University of Science and Technology, Islamabad, Pakistan
| | - Muzaffar Abbas
- Faculty of Pharmacy, Capital University of Science and Technology, Islamabad, Pakistan
| | - Lina Tariq Al Kury
- College of Natural and Health Sciences, Zayed University, Abu Dhabi, United Arab Emirates
| | - Fawad Ali Shah
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Mahboob Alam
- Faculty of Pharmacy, Capital University of Science and Technology, Islamabad, Pakistan
| | - Arif-ullah Khan
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Humaira Nadeem
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Mecca, Saudi Arabia
| | | | - Shupeng Li
- State Key Laboratory of Oncogenomics, School of Chemical Biology and Biotechnology, Shenzhen Graduate School, Peking University, Shenzhen, People’s Republic of China
| |
Collapse
|
21
|
Abstract
Phantom limb pain is highly prevalent after amputation. Treatment results will probably benefit from an interdisciplinary team and individually adapted surgical, prosthetic and pain medicine approaches. Introduction: Most patients with amputation (up to 80%) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility. Methods: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge. Results: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme. Discussion: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed.
Collapse
|
22
|
Bozzuto LM, Bartholomew AJ, Tung S, Sosin M, Tambar S, Cox S, Perez-Alvarez IM, King CA, Chan MC, Pittman TA, Tousimis EA. Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1763-1769. [PMID: 33451949 DOI: 10.1016/j.bjps.2020.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 10/18/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prepectoral (PP) breast reconstruction is now commonly performed and minimizes dissection of the pectoralis major muscle. Data are lacking comparing the immediate postoperative recovery of these patients as compared with traditional subpectoral (SP) breast reconstruction. METHODS From December 2015 to February 2017, 73 patients underwent PP prosthetic-based reconstruction at a single academic institution. PP cases were matched 1:1, by age and stage, to patients undergoing traditional SP reconstruction. Analysis of postoperative pain (visual analog scale) and opioid use (oral morphine equivalents, OME), was performed with both bi- and multivariate analyses. Additional outcomes explored included length of stay (LOS) and reconstructive intervention by plane of prosthetic reconstruction. RESULTS A total of 146 patients were included in the final cohort. PP reconstruction was associated with higher rates of direct-to-implant reconstruction (84.9% vs. 34.3%, p <0.001) and higher rates of initial prosthetic fill (401.53 mL vs. 280.88 mL, p<0.001). Patients undergoing PP reconstruction had significantly reduced postoperative pain (4.29 vs. 5.44, p<0.001) and in-hospital opioid use (62.63 mg OME vs. 98.84 mg OME, p = 0.03) compared with SP patients. This result remained in multivariate analysis for both pain (3.94 vs. 5.25, p<0.001) and opioid use (17.14 mg OME vs. 63.03 mg OME, p = 0.03). Additionally, patients undergoing PP reconstruction had significantly reduced overall LOS on multivariate analysis (21.36 vs. 26.28 h, p = 0.02). CONCLUSION Following mastectomy, PP breast reconstruction results in significantly reduced pain, opioid use, and hospital LOS compared with SP reconstruction.
Collapse
Affiliation(s)
- Laura M Bozzuto
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Alex J Bartholomew
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Shawndeep Tung
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Michael Sosin
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Stuti Tambar
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Comprehensive Blood and Cancer Center, Bakersfield, CA, United States
| | - Solange Cox
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Idanis M Perez-Alvarez
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Caroline A King
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Mabel C Chan
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Troy A Pittman
- Somenek+Pittman MD Advanced Plastic Surgery, Washington, DC, United States
| | - Eleni A Tousimis
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States.
| |
Collapse
|
23
|
Effectiveness of an Adapted Physical Activity Protocol for Upper Extremity Recovery and Quality of Life Improvement in a Case of Seroma after Breast Cancer Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217727. [PMID: 33105793 PMCID: PMC7660058 DOI: 10.3390/ijerph17217727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022]
Abstract
Growing evidence indicates that physical activity (PA) interventions may reduce upper limb function-limiting side effects of treatments and improve quality of life (QoL) of breast cancer (BC) survivors. However, the possible effectiveness of PA in cases developing seroma after BC treatment has yet to be demonstrated. Here, we describe for the first time the impact of a structured PA pathway (i.e., two cycles of eight-week adapted PA followed by eight-week adapted fitness) on upper limb disability and QoL in a peculiar case of chronic seroma as complication of reconstructive plastic surgery after left breast mastectomy and lymphadenectomy. A 56-year-old female BC survivor underwent a functional test battery (i.e., shoulder–arm mobility, range of motion, back flexibility and indirect assessment of pectoralis minor muscle) at baseline, during and after ending the structured PA pathway. Upper limb and back pain intensity and QoL were evaluated by numerical rating scale and Short Form-12 questionnaire, respectively. A relevant seroma reduction, an improvement in upper limb mobility and pain perception, and an overall increase in QoL were achieved after the structured PA intervention. Our findings suggest that an adapted PA intervention may represent an effective strategy for seroma treatment in BC survivors.
Collapse
|
24
|
King CA, Perez‐Alvarez IM, Bartholomew AJ, Bozzuto L, Griffith K, Sosin M, Thibodeau R, Gopwani S, Myers J, Fan KL, Tousimis EA. Opioid‐free anesthesia for patients undergoing mastectomy: A matched comparison. Breast J 2020; 26:1742-1747. [DOI: 10.1111/tbj.13999] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Caroline A. King
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Idanis M. Perez‐Alvarez
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Alex J. Bartholomew
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Laura Bozzuto
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Kayla Griffith
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Michael Sosin
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Renee Thibodeau
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Sumeet Gopwani
- Department of Anesthesia MedStar Georgetown University Hospital Washington DC USA
| | - Joseph Myers
- Department of Anesthesia MedStar Georgetown University Hospital Washington DC USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington DC USA
| | - Eleni A. Tousimis
- Department of Surgery Division of Breast Surgery MedStar Georgetown University Hospital Washington DC USA
| |
Collapse
|
25
|
Park JW, Kim JH, Woo KJ. Intraoperative Intercostal Nerve Block for Postoperative Pain Control in Pre-Pectoral versus Subpectoral Direct-to-Implant Breast Reconstruction: A Retrospective Study. ACTA ACUST UNITED AC 2020; 56:medicina56070325. [PMID: 32629834 PMCID: PMC7404693 DOI: 10.3390/medicina56070325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/24/2020] [Accepted: 06/27/2020] [Indexed: 11/20/2022]
Abstract
Background and Objectives: Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks (ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction. Materials and Methods: Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants. Results: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6, p = 0.047), lower maximum VAS scores on the operative day (5 versus 7.5, p = 0.030), and POD 1 (4 versus 6, p = 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7, p = 0.005), lower maximum VAS scores on the operative day (4.5 versus 8, p = 0.004), and POD 1 (4 versus 6, p = 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction. Conclusions: Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.
Collapse
|
26
|
Shiraishi M, Sowa Y, Fujikawa K, Kodama T, Okamoto A, Numajiri T, Taguchi T, Amaya F. Factors associated with chronic pain following breast reconstruction in Japanese women. J Plast Surg Hand Surg 2020; 54:317-322. [PMID: 32589082 DOI: 10.1080/2000656x.2020.1780246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chronic pain after breast surgery including breast reconstruction is a major concern for patients. However, the factors associated with chronic pain after breast surgery are uncertain in Japanese population. The aim of this study was to identify patient-specific and medical/surgical factors that predict chronic pain after breast surgery in Japanese patients. The subjects were 189 Japanese women undergoing breast surgery including tissue expander/implant (TE/implant), deep inferior epigastric perforator (DIEP) procedures and mastectomy only. Pain was assessed at one year postoperatively using a validated survey instrument: the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with postoperative pain. Surveys were completed by 141 subjects. A younger age (p = .04) and bilateral procedures (p < .05) were both closely associated with the extent of increased postoperative pain at 1 year using the MPQ-Total pain rating. Compared to total mastectomy only, TE/implant procedures showed a significantly lower visual analog scale (VAS) (p = .04) and present pain index (PPI) (p = .03) scores. No factor related to chronic pain was also significantly related to the frequency of pain medication use postoperatively or the effect of social life of the patients. This study identified patients at risk for greater chronic pain after breast surgery. These findings will allow surgeons to improve patient comfort, reduce clinical morbidity and enhance patient satisfaction with their surgical outcome. Abbreviations: BMI: body mass index; CI: confidence interval; DIEP: deep inferior epigastric perforator flap; MPQ: McGill pain questionnaire; PPI: present pain index; SD: standard deviation; SF-MPQ-JV: Japanese version of the short-form McGill pain questionnaire; TE: tissue expander; VAS: visual analog scale.
Collapse
Affiliation(s)
- Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kei Fujikawa
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuya Kodama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akiko Okamoto
- Department of Breast Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Toshiaki Numajiri
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Taguchi
- Department of Endocrinological and Breast Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Pain Management and Palliative Care Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
27
|
Nealon KP, Weitzman RE, Sobti N, Gadd M, Specht M, Jimenez RB, Ehrlichman R, Faulkner HR, Austen WG, Liao EC. Prepectoral Direct-to-Implant Breast Reconstruction: Safety Outcome Endpoints and Delineation of Risk Factors. Plast Reconstr Surg 2020; 145:898e-908e. [PMID: 32332523 DOI: 10.1097/prs.0000000000006721] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continued evolution of implant-based breast reconstruction involves immediate placement of the implant above the pectoralis muscle. The shift to prepectoral breast reconstruction is driven by goals of decreasing morbidity such as breast animation deformity, range-of-motion problems, and pain, and is made possible by improvements in mastectomy skin flap viability. To define clinical factors to guide patient selection for direct-to-implant prepectoral implant reconstruction, this study compares safety endpoints and risk factors between prepectoral and subpectoral direct-to-implant breast reconstruction cohorts. The authors hypothesized that prepectoral direct-to-implant breast reconstruction is a safe alternative to subpectoral direct-to-implant breast reconstruction. METHODS Retrospective chart review identified patients who underwent prepectoral and subpectoral direct-to-implant breast reconstruction, performed by a team of five surgical oncologists and two plastic surgeons. Univariate analysis compared patient characteristics between cohorts. A penalized logistic regression model was constructed to identify relationships between postoperative complications and covariate risk factors. RESULTS A cohort of 114 prepectoral direct-to-implant patients was compared with 142 subpectoral direct-to-implant patients. The results of the penalized regression model demonstrated equivalence in safety metrics between prepectoral direct-to-implant and subpectoral direct-to-implant breast reconstruction, including seroma (p = 0.0883), cancer recurrence (p = 0.876), explantation (p = 0.992), capsular contracture (p = 0.158), mastectomy skin flap necrosis (p = 0.769), infection (p = 0.523), hematoma (p = 0.228), and revision (p = 0.122). CONCLUSIONS This study demonstrates that prepectoral direct-to-implant reconstruction is a safe alternative to subpectoral direct-to-implant reconstruction. Given the low morbidity and elimination of animation deformity, prepectoral direct-to-implant reconstruction should be considered when the mastectomy skin flap is robust. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Kassandra P Nealon
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Rachel E Weitzman
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Nikhil Sobti
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Michele Gadd
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Michelle Specht
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Rachel B Jimenez
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Richard Ehrlichman
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Heather R Faulkner
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - William G Austen
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| | - Eric C Liao
- From the Divisions of Plastic and Reconstructive Surgery and Surgical Oncology, Department of Surgery, and the Department of Radiation Oncology, Massachusetts General Hospital
| |
Collapse
|
28
|
Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F. PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 75:664-673. [PMID: 31984479 PMCID: PMC7187257 DOI: 10.1111/anae.14964] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2019] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- A. Jacobs
- Department of Cardiovascular SciencesKULeuven and University Hospital LeuvenLeuvenBelgium
| | - A. Lemoine
- Service d'Anesthésie – Réanimation et Médecine Péri‐opératoireHopital TenonAPHPParis, France/Médecine‐Sorbonne UniversitéParisFrance
| | - G. P. Joshi
- Department of Anesthesiology and Pain ManagementUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - M. Van de Velde
- Department of Cardiovascular SciencesKULeuven and University Hospital LeuvenLeuvenBelgium
| | - F. Bonnet
- Service d'Anesthésie – Réanimation et Médecine Péri‐opératoireHopital TenonAPHPParis, France/Médecine‐Sorbonne UniversitéParisFrance
| |
Collapse
|
29
|
Lacroix C, Duhoux FP, Bettendorff J, Watremez C, Roelants F, Docquier MA, Potié A, Coyette M, Gerday A, Samartzi V, Piette P, Piette N, Berliere M. Impact of Perioperative Hypnosedation on Postmastectomy Chronic Pain: Preliminary Results. Integr Cancer Ther 2020; 18:1534735419869494. [PMID: 31441331 PMCID: PMC6710682 DOI: 10.1177/1534735419869494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objectives: The main aim of this prospective nonrandomized study was to evaluate if mastectomy performed with perioperative hypnosedation led to a lower incidence of chronic pain compared with mastectomy under general anesthesia. Methods: Forty-two breast cancer patients who underwent mastectomy either under GA (GA group, n = 21) or HYP (HYP group, n = 21) associated with local and/or regional anesthesia were included. The type of adjuvant therapy as well as the number of reconstructive surgical procedures were well balanced between the 2 groups. The average age of the patients and the type of axillary surgery were also equivalent. Incidence of postmastectomy chronic pain, lymphedema, and shoulder range of motion (ROM) were evaluated after a mean 4-year follow-up. Results: The study shows a statistically significant lower incidence of postmastectomy chronic pain in HYP group (1/21, 1 patient out of 21 experiencing pain) compared with GA group (9/21) with 9 patients out of 21 experiencing pain (P = .008). ROM for shoulder was also less frequently affected in the hypnosedation group, as only 1 patient had decreased ROM, instead of 7 in the other group (P = .04). Conclusions: Our study is the first to hint at the potential benefits of hypnosedation on postmastectomy chronic pain. Despite the limitations of this study (nonrandomized, small sample), preliminary results merit further study of hypnosedation.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Arnaud Potié
- 1 Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Maude Coyette
- 1 Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | | | | | - Nathan Piette
- 1 Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | |
Collapse
|
30
|
Altıparmak B, Korkmaz Toker M, Uysal AI, Dere Ö, Uğur B. Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial. Reg Anesth Pain Med 2020; 45:277-282. [DOI: 10.1136/rapm-2019-101114] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/03/2022]
Abstract
Background and objectivesMastectomy has many potential sources of pain. Rhomboid intercostal block (RIB) is a recently described plane block. The primary hypothesis of the study is that ultrasound-guided RIB combined with general anesthesia would accelerate global quality of recovery scores of patients following mastectomy surgery. Secondary hypothesis is that RIB would reduce postoperative opioid consumption, pain scores, and the need for rescue analgesia.MethodsPatients aged between 18 and 70 years, with American Society of Anesthesiologists physical status I–II and scheduled for an elective unilateral modified radical mastectomy surgery with axillary lymph node dissection were enrolled to the study. Following endotracheal intubation, patients were randomly allocated into two groups. Patients in the first group (group R) received ultrasound-guided RIB with 30 mL 0.25% bupivacaine. In the control group (group C), no block intervention was applied. All patients received intravenous dexamethasone 8 mg, dexketoprofen trometamol 50 mg intraoperatively and tramadol 1 mg/kg 30 min before the end of surgery for postoperative analgesia. All patients received intravenous morphine patient-controlled analgesia device at the arrival to the recovery room.ResultsThe descriptive variables of the patients were comparable between group R and group C. Mean quality of recovery-40 score at 24 hours was 164.8±3.9 in group R and 153.5±5.2 in group C (mean difference 11.4 (95% CI 8.8 to 13.9; p<0.001). At 24th hour, median morphine consumption was 5 mg (IQR 4–7 mg) in group R and 10 mg (IQR 8–13 mg) in group C, p<0.001. Intraoperative fentanyl administration, pain scores and the need for rescue postoperative analgesia was similar between groups.ConclusionsIn the current study, ultrasound-guided RIB promoted enhanced recovery and decreased opioid consumption after mastectomy surgery.Trial registration numberACTRN12619000879167.
Collapse
|
31
|
Mogensen N, Portman A, Mitchell K. Nonpharmacologic Approaches to Pain, Engorgement, and Plugging in Lactation: Applying Physical Therapy Techniques From Breast Cancer Care to Breastfeeding Patients. CLINICAL LACTATION 2020. [DOI: 10.1891/2158-0782.11.1.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IntroductionBreast and nipple pain is one of the most common reasons why mothers stop breastfeeding earlier than recommended. Once conditions such as subacute mastitis, oversupply, and dermatitis have been treated or ruled out, functional breast pain may persist.ReviewWe describe validated physical therapy techniques that may reduce chronic pain in breastfeeding. These techniques include lymphatic massage, reverse-pressure softening, kinesiology taping, neural mobilization, cupping, and therapeutic ultrasound.ConclusionWhile more commonly used in the breast cancer population after radiation and surgery, we propose these techniques may also prove efficacious in breastfeeding patients as well.
Collapse
|
32
|
Berry DL, Blonquist TM, Halpenny B, Hong F, Morrison-Ma SC, McCullough MC, Carelli K, Dominici LS, King TA. The Jacki Jacket after mastectomy with reconstruction: a randomized pilot study. Breast Cancer Res Treat 2019; 179:377-385. [PMID: 31612292 DOI: 10.1007/s10549-019-05465-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Breast cancer patients undergoing mastectomy with reconstruction (TM + R) often experience post-operative discomfort from surgical drains. Despite a variety of garment options for use in the post-operative period, high-quality data assessing the impact of specific garments on post-operative pain are lacking. We report the results of a prospective randomized trial assessing the impact of the Jacki Jacket (JJ), a long-sleeve jacket with inner drain receptacle pockets, on post-discharge pain and quality of life (QOL) after TM + R. METHODS Breast cancer patients undergoing TM + R at a single institution were randomized post-operatively to receive a JJ or usual care (UC). Participant-reported demographics, pain intensity, and QOL were collected on post-operative day 1 (T1). Following discharge, participants completed a daily pain and medication dairy (T2); on day of drain(s) removal (T3), participants again completed pain and QOL questionnaires. Linear models were used to evaluate associations between JJ use, post-operative pain, and QOL. RESULTS From 3/8/17 to 12/20/17, 139 women were randomized. All participants completed T1 measures, 102 returned the T2 diary, and 118 (84.9%) completed T3 questionnaires. There was no significant difference in pain scores between JJ and UC arms at any timepoint. Adjusting for surgery type, age, marital status, depression, and obesity, participants randomized to JJ reported significantly better body image scores (estimate = 12.94, p = 0.009). There were no adverse events. CONCLUSIONS Although JJ garment use did not impact post-operative pain intensity scores, the significant impact of JJ use on body image supports consideration for inclusion of such garments in post-operative care for patients undergoing TM + R. CLINICAL TRIAL REGISTRATION INFORMATION Registered with ClinicalTrials.gov, NCT number NCT02976103, November 18, 2016.
Collapse
Affiliation(s)
- Donna L Berry
- Dana-Farber Cancer Institute, Boston, MA, USA. .,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg; Room T615A, Seattle, WA, 98195-7266, USA.
| | | | | | | | | | - Michele C McCullough
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Laura S Dominici
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| |
Collapse
|
33
|
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Thoracic paravertebral block is the preferred regional anesthetic technique for breast cancer surgery, but concerns over its invasiveness and risks have prompted search for alternatives. Pectoralis-II block is a promising analgesic technique and potential alternative to paravertebral block, but evidence of its absolute and relative effectiveness versus systemic analgesia (Control) and paravertebral block, respectively, is conflicting. This meta-analysis evaluates the analgesic effectiveness of Pectoralis-II versus Control and paravertebral block for breast cancer surgery.
Methods
Databases were searched for breast cancer surgery trials comparing Pectoralis-II with Control or paravertebral block. Postoperative oral morphine consumption and difference in area under curve for pooled rest pain scores more than 24 h were designated as coprimary outcomes. Opioid-related side effects, effects on long-term outcomes, such as chronic pain and opioid dependence, were also examined. Results were pooled using random-effects modeling.
Results
Fourteen randomized trials (887 patients) were analyzed. Compared with Control, Pectoralis-II provided clinically important reductions in 24-h morphine consumption (at least 30.0 mg), by a weighted mean difference [95% CI] of −30.5 mg [−42.2, −18.8] (P < 0.00001), and in rest pain area under the curve more than 24 h, by −4.7cm · h [−5.1, −4.2] or −1.2cm [−1.3, −1.1] per measurement. Compared with paravertebral block, Pectoralis-II was not statistically worse (not different) for 24-h morphine consumption, and not clinically worse for rest pain area under curve more than 24 h. No differences were observed in opioid-related side effects or any other outcomes.
Conclusions
We found that Pectoralis-II reduces pain intensity and morphine consumption during the first 24 h postoperatively when compared with systemic analgesia alone; and it also offers analgesic benefits noninferior to those of paravertebral block after breast cancer surgery. Evidence supports incorporating Pectoralis-II into multimodal analgesia and also using it as a paravertebral block alternative in this population.
Collapse
|
34
|
Non-narcotic Perioperative Pain Management in Prosthetic Breast Reconstruction During an Opioid Crisis: A Systematic Review of Paravertebral Blocks. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2299. [PMID: 31624690 PMCID: PMC6635209 DOI: 10.1097/gox.0000000000002299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/24/2019] [Indexed: 12/27/2022]
Abstract
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.
Collapse
|
35
|
Sada A, Thiels CA, Britain MK, Dudakovic A, Bergquist WJ, Nickel SR, Moran MJ, Martinez-Jorge J, Jakub JW. Optimizing Discharge Opioid Prescribing Practices After Mastectomy With Immediate Reconstruction. Mayo Clin Proc Innov Qual Outcomes 2019; 3:183-188. [PMID: 31193969 PMCID: PMC6543550 DOI: 10.1016/j.mayocpiqo.2019.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/01/2019] [Accepted: 03/08/2019] [Indexed: 12/13/2022] Open
Abstract
A quality improvement initiative was conducted to provide guidelines for opioid prescribing following mastectomy with immediate reconstruction. Patients undergoing mastectomy with concurrent tissue expander reconstruction were surveyed at their first postoperative visit to determine use of pain medication, satisfaction, and refill rates. Opioid prescriptions were converted to total oral morphine milligram equivalents (MMEs). Guidelines for postdischarge prescriptions were developed. During phase I, 16 patients were surveyed to determine baseline prescribed MMEs and rate of satisfaction. A guideline was subsequently developed to standardize postdischarge prescribing (550 MMEs prescribed average risk vs 900 MMEs high risk), and the survey was repeated (phase II). Median 210 MMEs were used. Of the 23 patients, 1 required a refill, 83% were highly satisfied, and 77% of opioids were unused. Guidelines were further revised to limit prescribed opioids (290 MME average risk vs 450 MME high risk), and the survey was repeated (phase III). A median of 118 MMEs was used. Of the 22 patients, 5 required refills, 73% were highly satisfied, and 53% of opioids were unused. Phase IV included 27 patients. A median of 98 MMEs was used. Two patients required refills, 93% were highly satisfied, and 58% of opioids were unused. Our finding showed that there is significant overprescription of opioids after elective breast surgery. Practice guidelines can reduce the amount of opioids prescribed. Reducing excess opioids available in the community is a noble goal; however, it must be done cautiously, as decreased patient satisfaction can be an unintended consequence.
Collapse
Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Marcia K. Britain
- Division of Breast, Endocrine, Metabolic and GI Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Sarah R. Nickel
- Division of Breast, Endocrine, Metabolic and GI Surgery, Mayo Clinic, Rochester, MN
| | - Melissa J. Moran
- Division of Breast, Endocrine, Metabolic and GI Surgery, Mayo Clinic, Rochester, MN
| | | | - James W. Jakub
- Department of Surgery, Mayo Clinic, Rochester, MN
- Division of Breast, Endocrine, Metabolic and GI Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
36
|
Stein MJ, Waltho D, Ramsey T, Wong P, Arnaout A, Zhang J. Paravertebral blocks in immediate breast reconstruction following mastectomy. Breast J 2019; 25:631-637. [PMID: 31087471 DOI: 10.1111/tbj.13295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postoperative pain remains a major challenge following immediate breast reconstruction with 40% of patients experiencing acute pain and up to 60% developing chronic pain. Paravertebral blocks (PVB's) have emerged as a promising adjunct to standard analgesic protocols. The aim of this study was to assess the utility of PVB's in immediate breast reconstruction following mastectomy. METHODS A retrospective review of patients undergoing immediate breast reconstruction following mastectomy was performed. The primary outcome was postoperative pain measured by total oral morphine equivalent usage and self reported pain scores and secondary outcomes were length of stay in the PACU, complications, and OR delay. RESULTS Of 298 patients undergoing immediate breast reconstruction, 112(38%) underwent standard analgesic protocols and 186(62%) underwent PVB in addition to the standard protocol. PVB's were associated with reductions in average postoperative pain scores (2.8 vs 3.3, P = 0.002), total opiate consumption (52 units vs 63 units, P = 0.038) and time spent in the PACU 92 vs 142 minutes, P = 0.0228) compared to patients who had general anesthesia alone. The overall complication rate was 3.7% (7/186 patients), all which were minor complications such as headache, bloody tap, vasovagal episode and temporary weakness. The use of PVBs delayed the OR start time on average by 15 minutes (34 vs 49 minutes). CONCLUSIONS The present study offers one of the largest retrospective cohort studies to date evaluating the utility of PVB's in immediate breast reconstruction following mastectomy. We demonstrate that, PVB's in immediate breast reconstruction are associated with reductions in postoperative pain, narcotic usage and length of stay in PACU, but are associated with delays to the start time of the case. Anesthesiologists, plastic surgeons and hospital administrators must continue to work together to ensure this important and necessary service is administered in an efficient and cost effective manner.
Collapse
Affiliation(s)
- Michael J Stein
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Dan Waltho
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsey
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Patrick Wong
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Angel Arnaout
- Division of General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jing Zhang
- Division of Plastic and Reconstructive Surgery, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
37
|
Unplanned Emergency Department Visits within 30 Days of Mastectomy and Breast Reconstruction. Plast Reconstr Surg 2019; 142:1411-1420. [PMID: 30204678 DOI: 10.1097/prs.0000000000004970] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors' objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain. METHODS Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk. RESULTS Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted. CONCLUSIONS Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
|
38
|
Epidural Nerve Blocks Increase Intraoperative Vasopressor Consumption and Delay Surgical Start Time in Deep Inferior Epigastric Perforator Free Flap Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2105. [PMID: 30859053 PMCID: PMC6382231 DOI: 10.1097/gox.0000000000002105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/19/2018] [Indexed: 11/26/2022]
Abstract
Background: Epidural nerve blocks (EA) have been widely used in abdominal and thoracic surgery as an adjunct to general anesthesia (GA). The role for EA in microsurgical free flap breast reconstruction remains unclear with concerns regarding its impact on flap survival and operating room efficiency. The purpose of this study was to examine the effectiveness of epidural blocks in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods: A retrospective analysis of patients undergoing DIEP breast reconstruction under GA alone was compared with those receiving EA/GA. Electronic records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. The primary outcome was 48-hour narcotic usage and secondary outcomes were intraoperative vasopressor consumption, surgical delay, and safety profile. Results: Sixty-one patients underwent DIEP reconstruction, 46 (75%) underwent EA/GA and 15 (25%) underwent GA alone. Epidural blocks were associated with a significant delay in operating room start time (67.8 min versus 45.6 min; P = 0.0004.) Patients in the EA/GA group also had a significant increase in vasopressor use (n = 38 versus n = 8; P = 0.037); however, there was no difference in flap complication rate [1 (2%) versus 2 (13%); P = 0.15]. Postoperatively, patients who received an epidural block had a reduced average pain score (1.1 versus 2.2; P = 0.0235), but there was no difference in 48-hour narcotic usage. Conclusions: Although epidural blocks reduce postoperative pain following DIEP flap breast reconstruction, they increase intraoperative vasopressor use and delay the start time of the case. Further studies are required to elucidate whether the benefits of improved pain control outweigh the potential risk for increased surgical complications and increased health care costs.
Collapse
|
39
|
Evaluating Postoperative Narcotic Use in Prepectoral Versus Dual-plane Breast Reconstruction Following Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2082. [PMID: 30881831 PMCID: PMC6416120 DOI: 10.1097/gox.0000000000002082] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 10/26/2018] [Indexed: 12/03/2022]
Abstract
Background: The majority of postmastectomy breast reconstruction performed in the United States is device-based. Typically, a tissue expander or implant is placed in the dual-plane (ie, subpectoral). Prepectoral breast reconstruction with acellular dermal matrices following mastectomy is a relatively new technique that has favorable outcomes with minimal complications and satisfactory aesthetic results. Few studies have compared opioid use between the 2 approaches. This study compares duration of postoperative opioid use among patients undergoing prepectoral device-based breast reconstruction with those in whom dual-plane devices were placed. Methods: We reviewed the records of adult female patients aged 18 years or older who underwent prepectoral or dual-plane device-based breast reconstructions following mastectomy by one of the 2 plastic surgeons (A.M. or M.V.) from 2015 to 2017 at a large tertiary care hospital. Patients with a history of substance abuse, chronic pain, or who were already receiving opioid medication were excluded. Electronic medical records were reviewed and patient surveys were conducted during postoperative visits to determine postoperative opioid requirements. Results: During the study period, 58 patients underwent dual-plane breast reconstruction and 94 underwent prepectoral reconstruction. Demographics and comorbidities of the groups were similar. By multivariate regression analysis, the prepectoral reconstruction group required 33% fewer days on opioid analgesic medication (P = 0.016) and were 66% less likely to require opioid prescription refills (P = 0.027). There were no statistically significant differences in other outcomes or complications. Conclusion: Patients undergoing prepectoral tissue expander or implant-based reconstruction required fewer days of opioid pain medication than those managed with the dual-plane technique.
Collapse
|
40
|
Cattelani L, Polotto S, Arcuri MF, Pedrazzi G, Linguadoca C, Bonati E. One-Step Prepectoral Breast Reconstruction With Dermal Matrix–Covered Implant Compared to Submuscular Implantation: Functional and Cost Evaluation. Clin Breast Cancer 2018; 18:e703-e711. [DOI: 10.1016/j.clbc.2017.11.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/14/2017] [Accepted: 11/21/2017] [Indexed: 11/15/2022]
|
41
|
Zocca J, Valimahomed A, Yu J, Gulati A. A review of recent advances in the management of breast cancer related pain. BREAST CANCER MANAGEMENT 2018. [DOI: 10.2217/bmt-2018-0003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The incidence of breast cancer has stabilized over the past 10 years, while death rates have declined. Thus, many women are living with long-term effects of breast cancer, including pain syndromes relating to breast cancer. As our understanding of these types of pain syndromes improves, delivery of care to this population becomes paramount. In this review, we discuss advances in rehabilitation and interventional pain management to improve pain and symptom management. Appropriate use of physical therapy may significantly improve a patient's functional status, while fascial plane blocks can lead to pain relief which may last for months. Targeted therapies for pain relief may result in better quality of life for individuals suffering from breast cancer related pain.
Collapse
Affiliation(s)
- Jennifer Zocca
- Department of Pain Management, Maiden Lane Medical, 18 East, 41st Street, LLC, New York, NY, 10017, USA
| | - Ali Valimahomed
- Department of Pain Medicine & Anesthesia, Brigham & Women's Hospital: Boston Hospital & Medical Center, 75 Francis Street, Boston, MA, 02115, USA
| | - James Yu
- Touro College of Osteopathic Medicine, 230 West, 125th Street, New York, NY, 10027, USA
| | - Amitabh Gulati
- Department of Anesthesiology & Critical Care, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| |
Collapse
|
42
|
Liposomal Bupivacaine in Implant-Based Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1559. [PMID: 29263963 PMCID: PMC5732669 DOI: 10.1097/gox.0000000000001559] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/15/2017] [Indexed: 11/26/2022]
Abstract
Purpose: This study evaluates the role of liposomal bupivacaine in implant-based breast reconstruction. Methods: A prospective, randomized, single-blind trial of liposomal bupivacaine in implant-based breast reconstruction was performed. Patients in the control arm were treated with 20 mL 0.25% bupivacaine with epinephrine 1:200,000 to each breast pocket. Patients in the experimental arm were treated with 10 mL 1.3% liposomal bupivacaine delivered to each breast pocket. Pain scores were recorded over the course of patients’ hospital stay. Consumption of pain medications, benzodiazepines, and anti-emetics was monitored. Length of stay and other direct cost data were collected. Results: Twenty-four patients were enrolled, with 12 women randomized to each arm. Average postoperative pain scores were 3.66 for patients in the control arm and 3.68 for patients in the experimental arm. Opioid consumption was 1.43 morphine equivalent dosing/h for patients in the control arm and 0.76 morphine equivalent dosing/h for patients in the experimental arm (P = 0.017). Diazepam consumption was 0.348 mg/h for patients in the control arm and 0.176 mg/h for patients in the experimental arm (P = 0.011). Average length of hospital stay was 46.7 hours for patients in the control arm and 29.8 hours for patients in the experimental arm (P = 0.035). Average hospital charges were $18,632 for patients in the control arm and $10,828 for patients in the experimental arm (P = 0.039). Conclusions: Liposomal bupivacaine reduces opioid and benzodiazepine consumption, length of stay, and hospital charges. These data support a role for liposomal bupivacaine in implant-based breast reconstruction.
Collapse
|
43
|
Roth RS, Qi J, Hamill JB, Kim HM, Ballard TNS, Pusic AL, Wilkins EG. Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction. Breast 2017; 37:119-125. [PMID: 29145033 DOI: 10.1016/j.breast.2017.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/25/2017] [Accepted: 11/01/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction. MATERIALS AND METHODS Women (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics. RESULTS Nearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years. CONCLUSIONS The substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.
Collapse
Affiliation(s)
- Randy S Roth
- Department of Physical Medicine & Rehabilitation, University of Michigan Health Systems, Ann Arbor, MI, USA.
| | - Ji Qi
- Section of Plastic Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA.
| | - Jennifer B Hamill
- Section of Plastic Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA.
| | - Hyungjin M Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI, USA.
| | - Tiffany N S Ballard
- Section of Plastic Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA.
| | - Andrea L Pusic
- Memorial Sloan-Kettering Cancer Center, Department of Plastic & Reconstructive Surgery, New York, NY, USA.
| | - Edwin G Wilkins
- Section of Plastic Surgery, University of Michigan Health Systems, Ann Arbor, MI, USA.
| |
Collapse
|
44
|
Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use? Ann Plast Surg 2017; 78:254-259. [PMID: 28118232 DOI: 10.1097/sap.0000000000000873] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period. METHODS A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications. RESULTS We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group. CONCLUSIONS Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.
Collapse
|
45
|
Prepectoral Breast Reconstruction: A Safe Alternative to Submuscular Prosthetic Reconstruction following Nipple-Sparing Mastectomy. Plast Reconstr Surg 2017; 140:432-443. [DOI: 10.1097/prs.0000000000003627] [Citation(s) in RCA: 178] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
46
|
Oh J, Pagé MG, Zhong T, McCluskey S, Srinivas C, O'Neill AC, Kahn J, Katz J, Hofer SOP, Clarke H. Chronic Postsurgical Pain Outcomes in Breast Reconstruction Patients Receiving Perioperative Transversus Abdominis Plane Catheters at the Donor Site: A Prospective Cohort Follow-up Study. Pain Pract 2017; 17:999-1007. [PMID: 27996199 DOI: 10.1111/papr.12550] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 08/18/2016] [Accepted: 10/26/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is a debilitating and costly condition. Risk factors for CPSP after autologous breast reconstruction have not been clearly established. Previously, we demonstrated that transversus abdominis plane (TAP) catheters delivering intermittent local anesthetic reduced postoperative morphine consumption. This prospective follow-up study aimed to (1) compare the incidence of CPSP after autologous breast reconstruction between patients who received postoperative intermittent TAP catheters with bupivacaine or saline boluses and (2) assess the factors that contribute to the development and maintenance of CPSP in this study cohort. METHODS Ninety-three patients who underwent deep inferior epigastric artery perforator or muscle-sparing transverse rectus abdominis breast reconstruction were randomized to receive TAP catheters with bupivacaine or saline postoperatively. Subsequently, patients were followed for a year to assess persistent pain, pain severity, quality of life scores, and functional disability at 6 and 12 months after surgery. RESULTS Twenty-four percent and 23% of patients reported CPSP at 6 and 12 months, respectively. There were no significant differences between groups (bupivacaine vs. placebo) on pain-related variables, including incidence of CPSP. Patients who reported greater variability in pain scores at rest over the first 48 hours postoperatively were more likely to have CPSP 6 months, but not 12 months, later. CONCLUSIONS Acute postoperative pain variability may contribute to the development of CPSP up to 6 months after autologous breast reconstruction surgery. Neither postoperative use of bupivacaine vs. saline in the TAP catheters nor acute pain severity influenced the 6- or 12-month incidence of CPSP.
Collapse
Affiliation(s)
- Justin Oh
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - M Gabrielle Pagé
- Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Toni Zhong
- Division of Plastic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Coimbatore Srinivas
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Anne C O'Neill
- Division of Plastic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - James Kahn
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Joel Katz
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Psychology, York University, Toronto, Ontario, Canada
| | - Stefan O P Hofer
- Division of Plastic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada.,Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
47
|
|
48
|
Post-Mastectomy Pain Syndrome. PAIN MEDICINE 2017. [DOI: 10.1007/978-3-319-43133-8_130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
49
|
Lee KT, Bang SI, Pyon JK, Hwang JH, Mun GH. Method of breast reconstruction and the development of lymphoedema. Br J Surg 2016; 104:230-237. [DOI: 10.1002/bjs.10397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/07/2016] [Accepted: 09/06/2016] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Several studies have demonstrated an association between immediate autologous or implant-based breast reconstruction and a reduced incidence of lymphoedema. However, few of these have ocused specifically on whether the reconstruction method affects the development of lymphoedema. The study evaluated the potential impact of breast reconstruction modality on the incidence of lymphoedema.
Methods
Outcomes of women with breast cancer who underwent mastectomy and immediate reconstruction using an autologous flap or a tissue expander/implant between 2008 and 2013 were reviewed. Arm or hand swelling with pertinent clinical signs of lymphoedema and excess volume compared with those of the contralateral side was diagnosed as lymphoedema. The cumulative incidence of lymphoedema was estimated by the Kaplan–Meier method. Clinicopathological factors associated with the development of lymphoedema were investigated by Cox regression analysis.
Results
A total of 429 reconstructions (214 autologous and 215 tissue expander/implant) were analysed; the mean follow-up of patients was 45·3 months. The two groups had similar characteristics, except that women in the autologous group were older, had a higher BMI, and more often had preoperative radiotherapy than women in the tissue expander/implant group. Overall, the 2-year cumulative incidence of lymphoedema was 6·8 per cent (autologous 4·2 per cent, tissue expander/implant 9·3 per cent). Multivariable analysis demonstrated that autologous reconstruction was associated with a significantly reduced risk of lymphoedema compared with that for tissue expander/implant reconstruction. Axillary dissection, a greater number of dissected lymph nodes and postoperative chemotherapy were also independent risk factors for lymphoedema.
Conclusion
The method of breast reconstruction may affect subsequent development of lymphoedema.
Collapse
Affiliation(s)
- K-T Lee
- Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - S I Bang
- Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - J-K Pyon
- Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - J H Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - G-H Mun
- Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
50
|
Gould CR, Branagan G. Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction. Int J Colorectal Dis 2016; 31:1799-1804. [PMID: 27670429 DOI: 10.1007/s00384-016-2648-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
AIM Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients. METHOD Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery. RESULTS Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice. CONCLUSION Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.
Collapse
Affiliation(s)
- Charlotte R Gould
- Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK.
| | - Graham Branagan
- Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK
| |
Collapse
|