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Cirocchi R, Matteucci M, Randolph J, Duro F, Properzi L, Avenia S, Amato B, Iandoli R, Tebala G, Boselli C, Covarelli P, Sapienza P. Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis. World J Surg Oncol 2024; 22:92. [PMID: 38605346 PMCID: PMC11007944 DOI: 10.1186/s12957-024-03374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023. MATERIALS AND METHODS The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google. RESULTS We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%). CONCLUSIONS The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy.
| | - Matteo Matteucci
- Department of Medicine and Surgery, University of Milan, Milan, 20122, Italy
| | - Justus Randolph
- Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, 30341, USA
| | - Francesca Duro
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Luca Properzi
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Bruno Amato
- Department of Public Health, University of Naples "Federico II", Naples, 80131, Italy
| | - Ruggiero Iandoli
- Department of General Surgery, P.O Frangipane Ariano Irpino, Avellino, 83031, Italy
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, AOSP of Terni, Terni, 05100, Italy
| | - Carlo Boselli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Piero Covarelli
- Department of Medicine and Surgery, University of Perugia, Perugia, 06132, Italy
| | - Paolo Sapienza
- Department of Surgery, "Sapienza" University of Rome, Roma, 00161, Italy
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Al-dardery NM, Khaity AM, Albakri KA, Abdelsattar AT, Benmelouka AY, Lee T, Foppiani JA, Lin SJ. Preservation versus dissection of the intercostobrachial nerve for breast cancer surgeries: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:1003-1011. [PMID: 38333310 PMCID: PMC10849353 DOI: 10.1097/ms9.0000000000001622] [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: 06/08/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction This meta-analysis aimed to compare the efficacy of preservation of the intercostobrachial nerve (ICBN) versus its dissection for patients who underwent breast surgery. Methods The authors searched Web of Science, PubMed, Cochrane CENTRAL, and Scopus from inception until March 2023. Records were screened for eligible studies, and all relevant outcomes were pooled as an odds ratio (OR) with the corresponding 95% CI in the meta-analysis models using RevMan version 5.4. Results These results from 11 studies (1021 patients) favored preservation of the ICBN over its dissection in terms of anaesthesia and hypaesthesia [OR 0.50, (95% CI, 0.31-0.82); P = 0.006] and [OR 0.33, (95% CI, 0.16-0.68); P = 0.003], respectively. Whereas the overall effect favored ICBN dissection over preservation in the case of hyperaesthesia [OR 4.34, (95% CI, 1.43-13.15); P = 0.01]. Conversely, no significant variance was detected between the two groups in terms of pain [OR 0.68, (95% CI, 0.28-1.61) P = 0.38], paraesthesia [OR 0.88, (95% CI, 0.49-1.60); P = 0.68], and analgesia [OR 1.46, (95% CI, 0.05-45.69); P = 0.83]. Conclusion This meta-analysis revealed that the preservation of the ICBN has a significant effect on the disturbance of sensory parameters of hypaesthesia and anaesthesia when compared to its dissection. Further studies with larger sample sizes are recommended to precisely compare both techniques on a wider range of parameters.
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Affiliation(s)
| | | | | | | | | | | | - Jose A. Foppiani
- 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Olivencia-Delgado MN, Jusino-Álamo JF, De Miranda-Sánchez E, Quiñones-Rodríguez JI. From Cadaveric Dissection to the Operating Room: A Unilateral Double Intercostobrachial Nerve and the Implications in Axillary Lymph Node Dissection. Cureus 2023; 15:e36647. [PMID: 37102027 PMCID: PMC10123002 DOI: 10.7759/cureus.36647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
There are multiple treatment options for breast cancer (BC), including lumpectomy, chemo- and radiotherapy, complete mastectomy, and, when indicated, an axillary lymph node dissection. Such node dissections commonly lead the surgeon to encounter the intercostobrachial nerve (ICBN), which, if injured, leads to significant postoperative numbness of the upper arm. To assist in identifying the ICBN, we report a unilateral variation of a dual ICBN. The first ICBN (ICBN I) originates from the second intercostal space, as classically described in human anatomy. On the contrary, the second ICBN (ICBN II) originates from the second and third intercostal spaces. The anatomical knowledge of ICBN origin and its variations are crucial for axillary lymph node dissection in BC and other surgical interventions that involve the axillary region (e.g., regional nerve blocks). An iatrogenic injury of the ICBN has been associated with postoperative pain, paresthesia, and loss of upper extremity sensation in the dermatome supplied by this nerve. Therefore, maintaining the integrity of the ICBN is a worthy goal during axillary dissections in BC patients. Increasing the awareness of ICBN variants among surgeons reduces potential injuries, which would contribute to the BC patient's quality of life.
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Affiliation(s)
| | - Javier F Jusino-Álamo
- Department of Anatomy and Cell Biology, Universidad Central del Caribe School of Medicine, Bayamon, PRI
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Rokhtabnak F, Sayad S, Izadi M, Djalali Motlagh S, Rahimzadeh P. Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e119440. [PMID: 35070905 PMCID: PMC8771815 DOI: 10.5812/aapm.119440] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023] Open
Abstract
Background Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly. Objectives This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients. Methods In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed. Results Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups. Conclusions The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.
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Affiliation(s)
- Faranak Rokhtabnak
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Soheila Sayad
- Department of Surgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Izadi
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Djalali Motlagh
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Poupak Rahimzadeh
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
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van Tonder DJ, Lorke DE, Nyirenda T, Keough N. An uncommon, unilateral motor variation of the intercostobrachial nerve. Morphologie 2021; 106:209-213. [PMID: 34183262 DOI: 10.1016/j.morpho.2021.06.003] [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: 04/26/2021] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022]
Abstract
The intercostobrachial nerve (ICBN) is commonly defined as a purely sensory nerve supplying the skin of the lateral chest wall, axilla, and medial arm. However, numerous branching patterns and distributions, including motor, have been reported. This report describes an uncommon variant of the right ICBN observed in both an 86-year-old white female cadaver and a 77-year-old white male cadaver. In both cases the ICBN presented with an additional muscular branch, termed the "medial pectoral branch", piercing and therefore innervating the pectoralis major and minor muscles. Clinically, the ICBN is relevant during surgical access to the axilla and can result in sensory deficits (persistent pain/loss of sensory function) to this region following injury. However, damage to the variation observed in these cadavers may result in additional partial motor loss to pectoralis major and minor.
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Affiliation(s)
- D J van Tonder
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates.
| | - D E Lorke
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - T Nyirenda
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates
| | - N Keough
- Department of Anatomy and Cell Biology, College of Medicine and Health Sciences, Khalifa University, P.O. Box: 127788, Abu Dhabi, United Arab Emirates; Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
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Wang Z, Cui Y, Zheng M, Ge H, Huang Y, Peng J, Xie H, Wang S. Comparison of indocyanine green fluorescence and methylene blue dye in the detection of sentinel lymph nodes in breast cancer. Gland Surg 2020; 9:1495-1501. [PMID: 33224824 DOI: 10.21037/gs-20-671] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Previous studies have shown that sentinel lymph node biopsy (SLNB) can be successfully performed using methylene blue (MB); however, this method still has some drawbacks. Indocyanine green (ICG) fluorescence imaging, as a selective method, has the potential for guiding SLNB. This study aimed to compare the clinical sensitivity and efficacy between ICG and MB in SLNB in breast cancer. Methods A prospective study of 70 patients with biopsy-proven invasive breast cancer was conducted. Under the guidance of ICG and MB, administered by injection, SLNs were examined and removed. The detection rates, total number of SLNs detected, mean number of SLNs detected, and number of positive SLNs were compared between ICG and MB. Results The SLN detection rate was 100% and 93% (65/70) for ICG and MB, respectively. More SLNs were detected in the ICG group (243) than in the MB group (169). The mean number of SLNs detected with ICG and MB was 3.5±1.73 and 2.4±1.49, respectively. Moreover, there was a statistically significant difference between the number of SLNs detected using the two methods (t=6.648, P<0.05). Additionally, SLN metastasis was detected in 18 patients using ICG and 14 patients using MB; these patients immediately underwent axillary lymph node dissection (ALND). No postoperative complications were reported. Conclusions ICG demonstrated a higher detection rate and better accuracy, as well as a lower false negative rate, than MB in detecting SLNs in breast cancer. ICG has potential as an alternative tool that could be clinically applied to detect SLNs in breast cancer patients.
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Affiliation(s)
- Zhenghui Wang
- Department of Thyroid and Breast Surgery, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yangyang Cui
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingjie Zheng
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Han Ge
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Huang
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinghui Peng
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hui Xie
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shui Wang
- Department of Breast Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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