A review of postoperative analgesia for breast cancer surgery

Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials

Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.

Regeneration and anti-inflammatory effects of stem cells and their extracellular vesicles in gynecological diseases

There are many gynecological diseases, among which breast cancer (BC), cervical cancer (CC), endometriosis (EMs), and polycystic ovary syndrome (PCOS) are common and difficult to cure. Stem cells (SCs) are a focus of regenerative medicine. They are commonly used to treat organ damage and difficult diseases because of their potential for self-renewal and multidirectional differentiation. SCs are also commonly used for difficult-to-treat gynecological diseases because of their strong directional differentiation ability with unlimited possibilities, their tendency to adhere to the diseased tissue site, and their use as carriers for drug delivery. SCs can produce exosomes in a paracrine manner. Exosomes can be produced in large quantities and have the advantage of easy storage. Their safety and efficacy are superior to those of SCs, which have considerable potential in gynecological treatment, such as inhibiting endometrial senescence, promoting vascular reconstruction, and improving anti-inflammatory and immune functions. In this paper, we review the mechanisms of the regenerative and anti-inflammatory capacity of SCs and exosomes in incurable gynecological diseases and the current progress in their application in genetic engineering to provide a foundation for further research.

Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article

Background

Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients.

Methods

An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation.

Results

A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain.

Conclusion

The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.

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

Background and Aims

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

Material and Methods

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

Results

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

Conclusion

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

Efficacy of bi-level erector spinae plane block versus bi-level thoracic paravertebral block for postoperative analgesia in modified radical mastectomy: a prospective randomized comparative study

BACKGROUND

Postoperative analgesia in breast surgery is difficult due to the extensive nature of the surgery and the complex innervation of the breast; general anesthesia can be associated with regional anesthesia techniques to control intra- and post-postoperative pain. This randomized comparative study aimed to compare the efficacy of the erector spinae plane block and the thoracic paravertebral block in radical mastectomy procedures with or without axillary emptying.

METHODS

This prospective randomized comparative study included 82 adult females who were randomly divided into two groups using a computer-generated random number. Both groups, Thoracic Paraverterbal block group and Erector Spinae Plane Block group (41 patients each), received general anesthesia associated with a multilevel single-shot thoracic paravertebral block and a multilevel single-shot erector spinae plane block, respectively. Postoperative pain intensity (expressed as Numeric Rating Scale), patients who needed rescue analgesic, intra- and post-operative opioid consumption, post-operative nausea and vomiting, length of stay, adverse events, chronic pain at 6 months, and the patient's satisfaction were recorded.

RESULTS

At 2 h (p < 0.001) and 6 h (p = 0.012) the Numeric Rating Scale was significantly lower in Thoracic Paraverterbal block group. The Numeric Rating Scale at 12, 24, and 36 postoperative hours did not show significant differences. There were no significant differences also in the number of patients requiring rescue doses of NSAIDs, in intra- and post-operative opioid consumption, in post-operative nausea and vomiting episodes and in the length of stay. No failures or complications occurred in the execution of techniques and none of the patients reported any chronic pain at six months from the surgery.

CONCLUSIONS

Both thoracic paravertebral block and erector spinae plane block can be effectively used in controlling post-mastectomy pain with no significant differences between the two blocks.

TRIAL REGISTRATION

The study was prospectively registered on Clinicaltrials.gov (trial identifier NCT04457115) (first registration 27/04/2020).

Long-term sciatic nerve block led by a supramolecular arrangement of self-delivery local anesthetic nano systems

Classical local anesthetics are unsuitable to treat regional pain lasting several days due to their limited duration and systemic toxicity. Self-delivery nano systems without excipients were designed for long-term sensory blocks. 1a self-assembled into different vehicles with different fractions of intermolecular π-π stacking, transported itself into nerve cells, and released single molecules slowly to achieve long-term duration for rats' sciatic nerve block for 11.6 h in water, 12.1 h in water with CO₂ and 3.4 h in NS (normal saline). After the counter ions were changed to SO₄^2-, 1e can self-assemble into vesicles and prolong the duration to 43.2 h, which was much longer than the 3.8 h led by (s)-bupivacaine hydrocloride (0.75%). This was mainly caused by the enhancement of self-release and counter ion exchange inside nerve cells, which were affected by the gemini surfactant structure, pK_a of the counter ions and π-π stacking interactions.

Paravertebral block versus erector spinae plane block for analgesia in modified radical mastectomy: a randomized, prospective, double-blind study

BACKGROUND

Pain control after breast surgery is crucial and supported with regional techniques. Paravertebral block (TPVB) is shown to be effective in postoperative pain management. Erector spinae plane block (ESPB) is assumed to have a similar analgesic effect as an easier and safer block. Our aim was to compare TPVB and ESPB for modified radical mastectomy (MRM) in terms of analgesic efficiency and dermatomal spread.

METHODS

Patients were randomized into Group E (ESPB) and Group P (TPVB). Total 83 patients completed study 42 in Group E and 41 in Group P. Blocks were performed under ultrasonography with 20 mL 0.375% bupivacaine at T4 prior to surgery. T1-10 dermatomal block was examined via pin-prick sensation on the midaxillary and midclavicular lines. Primary outcome was 24-hour morphine consumption. Dermatomal coverage, postoperative 0th minute, 30th minute, 1st, 4th, 6th, 12th and 24th hours pain scores, rescue analgesia requirement and adverse events were secondary outcomes.

RESULTS

Morphine consumption was lower in Group P (19.2±2.9 vs. 21±3.1, P=0.007; mean difference 1.8 mg, 95%CI=0.48-3.1 mg). The number of dermatomes with total loss of sensation was higher in Group P. Pain scores were significantly lower in Group P at all time points. The incidence of complications and adverse events was similar in both groups.

CONCLUSIONS

Thoracal paravertebral block reduced morphine consumption compared to ESPB after MRM, albeit a small difference. A through coverage of TPVB may be preferred with experienced operators in MRM due to lower pain scores.

Comparing Effect of Adding Ketamine versus Dexmedetomidine to Bupivacaine in Pecs-ⅠⅠ Block on Postoperative Pain Control in Patients Undergoing Breast Surgery

BACKGROUND

Pecs-II block has previously and successfully demonstrated a good quality of perioperative analgesia for breast surgery.

OBJECTIVE

This study aimed to compare the quality of postoperative pain control when adding either ketamine or dexmedetomidine to bupivacaine 0.25% for Pecs-II block.

METHODS

This prospective randomized double-blind study was conducted on 159 female patients with American society of anesthesiologist (ASA) physical status class I-III scheduled to have modified radical mastectomy. Patients were randomly assigned into three groups. Each group included 53patients to receive ultrasound guided Pecs-II blocks with either 32 mL of 0.25% bupivacaine added to ketamine hydrochloride 1 mg/kg (BK group), 32 mL of 0.25%bupivacaine added to dexmedetomidine 1 ug/kg (BD group) or 32 mL of 0.25% bupivacaine only (B group).The primary outcome of this study was the total postoperative morphine consumption for the first 24 hours postoperatively. The time of the first request of analgesia, the pain scores at rest of ipsilateral arm, and the intra-operative fentanyl requirements, were the secondary outcome measures. Any side effects occurred were recorded.

RESULTS

The total postoperative morphine consumption was significantly lower in patients received bupivacaine with addition of either ketamine (BK group), (10.3±2.6 mg), or dexmedetomidine (BD group), (3.8±0.2 mg) respectively, versus patients received only bupivacaine (B group), (16.9±5.3 mg). Both ketamine (BK group) and dexmedetomidine (BD group) added to bupivacaine significantly prolonged the time to first analgesic request (16.7±4.5 h), (21.6±1.6 h) in both groups respectively compared to patients received bupivacaine alone (B group), (11.5±1.2 h).The pain score was variable between the three groups over different times during the first 24 hours postoperatively. There was no significant difference in perioperative hemodynamics, O2 saturation, sedation scores or side effects observed between the three groups. Patient satisfaction was reported to be the best in patients received dexmedetomidine added to bupivacaine than the other patients who received ketamine as an additive or those who received bupivacaine alone.

CONCLUSION

Adding dexmedetomidine to bupivacaine provides more effective postoperative pain control than adding ketamine during Pecs-II blocks for breast cancer surgery.

Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group

BACKGROUND

Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM).

METHODS

The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation.

RESULTS

Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities.

CONCLUSIONS

Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.

A comparative study on analgesic and non-analgesic outcomes of inter pleural analgesia compared to thoracic epidural analgesia in open pancreatico-duodenectomy

Backgrounds/Aims

Thoracic epidural analgesia (TEA) is an established analgesic method in open Kausch-Whipple pancreaticoduodenectomy (KWPD). Although, it can cause hemodynamic instability and neurological complications. Inter pleural analgesia (IPA) is an alternative option. We aim to evaluate the effectiveness of IPA versus TEA after KWPD.

Methods

We retrospectively studied the efficacy of IPA against TEA in patients, operated by a single surgeon. The primary outcome was the analgesic efficacy and secondary outcomes were analgesia-related complications, inotrope use, and duration.

Results

Forty patients (TEA, 22; IPA, 18) were included. Both groups were well matched for patient characteristics, type, and duration of surgery. TEA was associated with higher analgesia-related complications (n = 8, 36.4% vs. n = 1, 5.6%; p = 0.027). TEA complications included analgesia not working (n = 4), leakage (n = 2), refractory hemodynamic instability (n = 1), and lower limb anaesthesia (n = 1). One patient in the IPA group encountered leakage. TEA was associated with longer inotrope requirement (35 vs. 18 hours; p = 0.047). There was no significant difference in intensive care unit (ITU) admission rate (81.8% vs. 77.8%; p > 0.999), median ITU stay (3 vs. 2 days, p = 0.385), or hospital stay (11 days in both groups).

Conclusions

In open KWPD, IPA is not inferior to TEA in its efficacy of pain control. IPA was associated with less analgesia-related complications and shorter inotrope requirements. However, this was a small retrospective study. Larger randomized controlled trials are needed to study the effectiveness of IPA.

Ultrasound-guided single thoracic paravertebral nerve block and erector spinae plane block for perioperative analgesia in thoracoscopic pulmonary lobectomy: a randomized controlled trial

OBJECTIVE

To explore the effect of a single preoperative ultrasound-guided thoracic paravertebral nerve block (TPVB) and erector spinae plane block (ESPB) for perioperative analgesia in thoracoscopic pulmonary lobectomy.

METHODS

Seventy-two patients aged 40-70 years who underwent thoracoscopic pulmonary lobectomy under general anesthesia were enrolled and randomly divided into the control group (Group C), the TPVB group (Group T) and the ESPB group (Group E). The primary observation indicators included the visual analogue scale (VAS) at 1, 6, 12, 24, and 48 h postoperatively at rest and with a cough. The secondary observation indicators included the intraoperative sufentanil consumption, anesthesia awakening time and extubation time, the sufentanil consumption in the analgesic pump, and flurbiprofen ester consumption for remedial analgesia within 48 h after surgery and the incidence of postoperative adverse events.

RESULTS

The intraoperative sufentanil consumption, anesthesia awakening time, and extubation time were lower in groups T and E than those in group C (p < 0.05). Patients in group T had lower VAS scores at rest and with a cough at 1, 6, and 12 h postoperatively than in group C at the same time points (p < 0.05). The VAS scores at rest at 1 and 6 h postoperatively and coughing status at 1, 6, and 12 h postoperatively were lower in group E than in group C at the same time points (p < 0.05).

CONCLUSION

The ultrasound-guided preoperative single TPVB and ESPB for thoracoscopic pulmonary lobectomy could both reduce the postoperative pain VAS score and reduce the dose of perioperative sufentanil and postoperative remedial analgesics.

A Web- and Mobile-Based Intervention for Women Treated for Breast Cancer to Manage Chronic Pain and Symptoms Related to Lymphedema: Results of a Randomized Clinical Trial

BACKGROUND

The-Optimal-Lymph-Flow (TOLF) is a patient-centered, web- and mobile-based mHealth system that delivers safe, easy, and feasible digital therapy of lymphatic exercises and limb mobility exercises.

OBJECTIVE

The purpose of this randomized clinical trial (RCT) was to evaluate the effectiveness of the web- and mobile-based TOLF system for managing chronic pain and symptoms related to lymphedema. The primary outcome includes pain reduction, and the secondary outcomes focus on symptom relief, limb volume difference measured by infrared perometer, BMI, and quality of life (QOL) related to pain. We hypothesized that participants in the intervention group would have improved pain and symptom experiences, limb volume difference, BMI, and QOL.

METHODS

A parallel RCT with a control-experimental, pre- and posttest, and repeated-measures design were used. A total of 120 patients were recruited face-to-face at the point of care during clinical visits. Patients were randomized according to pain in a 1:1 ratio into either the arm precaution (AP) control group to improve limb mobility and arm protection or The-Optimal-Lymph flow (TOLF) intervention group to promote lymph flow and limb mobility. Trial outcomes were evaluated at baseline and at week 12 after the intervention. Descriptive statistics, Fisher exact tests, Wilcoxon rank-sum tests, t test, and generalized linear mixed effects models were performed for data analysis.

RESULTS

At the study endpoint of 12 weeks, significantly fewer patients in the TOLF intervention group compared with the AP control group reported chronic pain (45% [27/60] vs 70% [42/60]; odds ratio [OR] 0.39, 95% CI 0.17-0.90; P=.02). Patients who received the TOLF intervention were significantly more likely to achieve a complete reduction in pain (50% [23/46] vs 22% [11/51]; OR 3.56, 95% CI 1.39-9.76; P=.005) and soreness (43% [21/49] vs 22% [11/51]; OR 2.60, 95% CI 1.03-6.81; P=.03). Significantly lower median severity scores were found in the TOLF group for chronic pain (MedTOLF=0, IQR 0-1 vs MedAP=1, IQR 0-2; P=.02) and general bodily pain (MedTOLF=1, IQR=0-1.5 vs MedAP=1, IQR 1-3; P=.04). Compared with the AP control group, significantly fewer patients in the TOLF group reported arm/hand swelling (P=.04), heaviness (P=.03), redness (P=.03), and limited movement in shoulder (P=.02) and arm (P=.03). No significant differences between the TOLF and AP groups were found in complete reduction of aching (P=.12) and tenderness (P=.65), mean numbers of lymphedema symptom reported (P=.11), ≥5% limb volume differences (P=.48), and BMI (P=.12).

CONCLUSIONS

The TOLF intervention had significant benefits for breast cancer survivors to manage chronic pain, soreness, general bodily pain, arm/hand swelling, heaviness, and impaired limb mobility. The intervention resulted in a 13% reduction (from 40% [24/60] to 27% [16/60]) in proportions of patients who took pain medications compared with the AP control group, which had a 5% increase (from 40% [24/60] to 45% [27/60]). A 12% reduction (from 27% [16/60] to 15% [9/60]) in proportions of patients with ≥5% limb volume differences was found in the TOLF intervention, while a 5% increase in the AP control group (from 40% [24/60] to 45% [27/60]) was found. In conclusion, the TOLF intervention can be a better choice for breast cancer survivors to reduce chronic pain and limb volume.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02462226; https://clinicaltrials.gov/ct2/show/NCT02462226.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.5104.

Role of sex hormones in modulating breast and ovarian cancer associated pain

According to the National Cancer Institute in 2020 there will be an estimated 21,750 new ovarian cancer cases and 276,480 new breast cancer cases. Both breast and ovarian cancer are hormone dependent cancers, meaning they cannot grow without the presence of hormones. The two most studied hormones in these two cancers are estrogen and progesterone, which are also involved in the modulation of pain. The incidence of pain in breast and ovarian cancer is very high. Research about mechanisms involved in modulation of pain by hormones are still being debated, as some studies find estrogen to be anti-nociceptive and others pro-nociceptive in pain studies. Moreover, analgesic treatments for breast and ovarian cancer-associated pain are limited and often ineffective. In this review, we will focus on estrogen and progesterone mechanisms of action in modulation of pain and cancer. We will also discuss new treatment options for these types of cancer and associated-pain.

A systematic review and meta-analysis of the effects of general anesthesia combined with continuous paravertebral block in breast cancer surgery and postoperative analgesia

Background

This study aimed to compare the effects of general anesthesia (GA) combined with continuous paravertebral block (CPVB) in breast cancer surgery via systematic review and meta-analysis, in order to provide a theoretical basis for the clinical use of CPVB surgical analgesia.

Methods

A search of the PubMed, Embase, Medline, Ovid, Springer, and Web of Science databases was conducted to screen clinical trials on GA + CPVB for breast cancer surgery published before December 31, 2020. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was adopted for bias risk assessment, and Review Manager 5.3 software (RevMan, The Cochrane Collaboration, http://tech.cochrane.org/revman) was applied for meta-analysis of the literature.

Results

A total of 15 studies that satisfied the requirements were included, involving a total of 1,435 research subjects. The results of our meta-analysis showed the following: the visual analogue scale (VAS) score of the observation group (group A) was significantly reduced [mean difference (MD) =-0.68; 95% confidential interval (CI): -1.04 - -0.33; Z=3.80; P=0.0001]; the level of monocyte chemoattractant protein -1 (MCP-1) was notably decreased (MD =-18.64; 95% CI: -29.68 - -7.61; Z=3.31; P=0.0009); the level of tumor necrosis factor-α (TNF-α) was markedly lower (MD =-1.89; 95% CI: -2.66 - -1.13; Z=4.87; P<0.00001); the interleukin-6 (IL-6) level was obviously reduced (MD =-12.10; 95% CI: -19.22 - -4.99; Z=3.33; P=0.0009); and the incidence of postoperative adverse reactions was substantially decreased (MD = 0.16; 95% CI: 0.07-0.36; Z=4.47; P<0.00001). Compared with group B, the differences of the above five indicators showed statistical significance. In addition, the heart rate (HR) (MD =-1.56; 95% CI: -6.20 - 3.08; Z=0.66; P=0.51), mean arterial pressure (MAP) (MD = 4.66; 95% CI: -0.12 -9.43; Z=1.91; P=0.06), Ramsay score (MD =0.44; 95% CI: -0.06-0.93; Z=1.73; P=0.08) of patients in group A showed no statistical differences compared to group B.

Conclusions

GA + CPVB applied to breast cancer surgery for analgesia can reduce the levels of MCP-1, TNF-α, and IL-6 in patients, thereby providing good postoperative analgesia. Therefore, GA + CPVB could effectively reduce the incidence of pain and adverse reactions in patients, and is effective for analgesia in breast cancer surgery.

Safety and Efficacy of Dexmedetomidine in Breast Surgeries: A Systematic Review and Meta-Analysis

PURPOSE

Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries.

DESIGN

Systematic review and meta-analysis.

METHODS

The present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019.

FINDINGS

Twelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery.

CONCLUSIONS

The results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.

The Effect of Ketamine on Acute and Chronic Wound Pain in Patients Undergoing Breast Surgery: A Meta-Analysis and Systematic Review

INTRODUCTION

Perioperative use of ketamine has been discussed widely in many kinds of surgery. The aim of our study was to evaluate the short-term and long-term benefits and safety of ketamine after breast surgery.

METHOD

We performed a quantitative systematic review. We included randomized controlled trials that compared intravenous administration of ketamine to a placebo control group, or compared bupivacaine in combination with ketamine to bupivacaine alone in thoracic paravertebral blocks or pectoral blocks among patients undergoing breast surgery. The primary outcome was postoperative pain intensity. Secondary outcomes included cumulative opioid consumption during the 0- to 24-hour postoperative period, the effect on postmastectomy pain syndrome, the effect on postoperative depression, and the adverse events associated with the use of ketamine.

RESULTS

Thirteen randomized controlled trials with 1,182 patients were included for analysis. Compared with placebo, intravenous ketamine was effective in reducing wound pain intensity during the first 6 hours after surgery (weighted mean difference [WMD] -0.83; 95% confidence interval [CI] -1.65, -0.01; P = 0.048) and during the first 24 hours after surgery (WMD -0.65; 95% CI -0.95, -0.35; P < 0.001), and in decreasing opioid consumption (WMD -4.14; 95% CI -8.00, -0.29; P = 0.035) during the first 24 hours after surgery, without increasing the risks for gastrointestinal and central nervous system adverse events. Adding ketamine to bupivacaine in thoracic paravertebral blocks was also effective in reducing postoperative wound pain during the first 6 hours after surgery (WMD -0.59; 95% CI, -1.06, -0.12; P = 0.014) and during the first 24 hours after surgery (WMD -0.90; 95% CI -1.27, -0.53; P < 0.001), and in decreasing opioid consumption (WMD - 4.59; 95% CI -5.76, -3.42; P < 0.001) during the first 24 hours after surgery. Perioperative use of ketamine was associated with improved postoperative depression symptoms (standardized mean difference -0.80; 95% CI - 1.34, -0.27; P = 0.003) and less incidence of postmastectomy pain syndrome (relative risk 0.79; 95% CI 0.63, 0.99; P = 0.043).

CONCLUSION

Ketamine is an effective and safe multimodal analgesic in patients undergoing breast surgery, administered both intravenously and when added to bupivacaine in paravertebral blocks. In addition, ketamine showed a long-term benefit for preventing postoperative depression and postmastectomy pain syndrome.

Plant Extracts as Possible Agents for Sequela of Cancer Therapies and Cachexia

Cancer is a leading cause of the death worldwide. Since the National Cancer Act in 1971, various cancer treatments were developed including chemotherapy, surgery, radiation therapy and so forth. However, sequela of such cancer therapies and cachexia are problem to the patients. The primary mechanism of cancer sequela and cachexia is closely related to reactive oxygen species (ROS) and inflammation. As antioxidant properties of numerous plant extracts have been widely reported, plant-derived drugs may have efficacy on managing the sequela and cachexia. In this study, recent seventy-four studies regarding plant extracts showing ability to manage the sequela and cachexia were reviewed. Some plant-derived antioxidants inhibited cancer proliferation and inflammation after surgery and others prevented chemotherapy-induced normal cell apoptosis. Also, there are plant extracts that suppressed radiation-induced oxidative stress and cell damage by elevation of glutathione (GSH), superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and regulation of B-cell lymphoma 2 (BcL-2) and Bcl-2-associated X protein (Bax). Cachexia was also alleviated by inhibition of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1) by plant extracts. This review focuses on the potential of plant extracts as great therapeutic agents by controlling oxidative stress and inflammation.

Postoperative pain management in obstetrics and gynecology

The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon’s individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.

Efficacy of erector spinae plane block for postoperative analgesia in total mastectomy and axillary clearance: A randomized controlled trial

Background:

The erector spinae plane block is a newer technique of analgesia to the chest wall.

Objective:

The study was carried out to establish the efficacy and safety of this block in patients undergoing total mastectomy and axillary clearance.

Design:

Prospective randomized controlled study.

Setting:

Single tertiary care center, the study was conducted over a period of 1 year.

Patients:

65 patients were included; final analysis was done for 60 female patients undergoing total mastectomy and axillary clearance under general anesthesia were randomly allocated to two groups.

Intervention:

Group B (block group) received ultrasound-guided erector spinae plane block at T5 level with ropivacaine (0.5%, 0.4 mL/kg) while the control group did not receive any intervention. Postoperatively, patients in both groups received morphine via intravenous patient-controlled analgesia device. Patients were followed up for 24 h postoperatively.

Main Outcome Measures:

The 24-hour morphine consumption was considered as the primary outcome and secondary outcomes included time to first rescue analgesia, pain scores at 0, ½, 1, 2, 4, 6, 8, 12, and 24 h and characteristics and complications associated with block procedure.

Results:

The 24-hour morphine consumption was 42% lower in block group compared to control group [mean (SD), 2.9 (2.5) mg vs 5.0 (2.1) mg in group B and group C, respectively, P = 0.01]. The postoperative pain score was lower in group B vs group C at 0, 1/2, 1, 2, 4, 6, 12, and 24 h (P < 0.05). 26 patients in group C against 14 in group B used rescue analgesia within 1 h of surgery (P = 0.01).

Conclusion:

Erector spinae block may prove to be a safe and reliable technique of analgesia for breast surgery. Further studies comparing this technique with other regional techniques are required to identify the most appropriate technique.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q

Purpose

An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis.

Methods

Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis.

Results

Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (β = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (β = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (β = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05).

Conclusion

Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial

Background and objectives

Mastectomy 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.

Methods

Patients 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.

Results

The 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.

Conclusions

In the current study, ultrasound-guided RIB promoted enhanced recovery and decreased opioid consumption after mastectomy surgery.

Trial registration number

ACTRN12619000879167.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

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 &lt; 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.

Pain and opioid prescriptions vary by procedure after breast surgery

BACKGROUND

With the opioid epidemic in the United States, evaluating opioid prescribing patterns is essential. We evaluated opioids prescribed at discharge following breast surgery and their association with patient factors and pain scores.

METHODS

We retrospectively identified adult patients who underwent a mastectomy for cancer at Mayo Clinic sites from January 2010 to December 2016. Pain scores and prescription data were compared across operations and patient factors by univariate and multivariable analyses.

RESULTS

Of 4021 patients, 3782 (94.1%) received an opioid prescription. Median oral milligram morphine equivalents (MME) were similar across all site-specific procedure groups (medians ranging from 225 to 375) while pain scores ranged from 1 to 4. Patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) reported the greatest pain scores. Pain scores did not vary with age or diagnosis for patients undergoing unilateral mastectomy or BM with lymph node surgery and IBR procedures. On multivariable analysis, variables associated with a MME discharge prescription >Q₄ values included age, body mass index, site, year, inpatient status, and pain before discharge >3.

CONCLUSION

Patient-reported pain following breast surgery varied by procedure, while MMEs prescribed remained similar. This suggests current opioid prescribing does not reflect intensity of pain and requires further research to optimize discharge opioid prescribing practices.

Comparative study of ultrasound-guided paravertebral block versus intravenous tramadol for postoperative pain control in percutaneous nephrolithotomy

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure for renal calculi, and nephrostomy tubes lead to postoperative pain after PCNL. Regional techniques (e.g., epidural analgesia and peripheral blocks) and opioids are applied for postoperative pain treatment. The aim of this study was to compare effectiveness of ultrasound-guided paravertebral block (PVB) and tramadol on postoperative pain in patients who underwent PCNL.

METHOD

Fifty-three patients were included in this prospective randomized study. The patients were allocated into two groups: the PVB group (group P, n = 26) and the tramadol group (group T, n = 27). All patients were administered standard general anaesthesia. Ultrasound-guided PVB was performed at the T11- L1 levels using 0.5% bupivacaine for a total dose of 15 mL in group P. Patients in group T were intravenously administered a loading dose of 1 mg/kg tramadol. Patients in both groups were given patient-controlled analgesia. Haemodynamic parameters, visual analogue scale (VAS) scores, side effects, and complications, tramadol consumption and additional analgesic requirements of the patients were recorded after surgery.

RESULTS

Haemodynamic parameters were statistically similar between the groups. The VAS in group P were statistically lower than in group T. In the 24-h period after surgery, total PCA tramadol consumption was statistically lower in group P than in group T. The use of supplemental analgesic in group T was higher than in group P.

CONCLUSIONS

Ultrasound-guided PVB was found to be an effective analgesia compared to tramadol, and no additional complications were encountered.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02412930 , date of registration: March 27, 2015, retrospectively registered.

Feasibility of Cervical Epidural Anesthesia for Breast Cancer Surgery

Background

Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse.

Methods

Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed.

Results

In 26 patients (66,7%, 95% CI 51,7–81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0–7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7–19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7–30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4–96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed.

Discussion

Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques.