|Year : 2020 | Volume
| Issue : 1 | Page : 71-77
Pectoral nerve block for postoperative analgesia in breast cancer surgery
Mohamed O Alfy1, Manal Foad2
1 Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Anesthesiology and Intensive Care, Al Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||24-Jan-2020|
|Date of Decision||07-Feb-2020|
|Date of Acceptance||09-Feb-2020|
|Date of Web Publication||20-Apr-2020|
MD Mohamed O Alfy
Source of Support: None, Conflict of Interest: None
Background Breast cancer is the most common malignancy in women and its incidence continues to increase. Surgery is one of the mainstays of treatment of breast cancer, and modified radical mastectomy is one of the standard treatments, Pectoral nerve (PECS I and PECS II) block was reported to be good analgesia for breast surgery.
Aim To compare PECS blocks in combination with general anesthesia versus general anesthesia alone in modified radical mastectomy surgery.
Patients and methods Patients were classified randomly into two groups in a blinded manner, and each one contained 30 patients. Control group received general anesthesia only. PECS group received general anesthesia plus PECS guided by ultrasound (PECS I and PECS II).
Results There was a statistically significant decrease in fentanyl requirement in the PECS group compared with the control group. There was a high statistically significant decrease in visual analog scale in the PECS group compared with the control group. There was a statistically significant increase the first time of rescue dose of opioid in PECS group compared with control group.
Conclusion PECS blocks can produce excellent pain relief during postoperative hours. They hold great promise as under ultrasonic guidance they have become simple and easy-to-learn techniques.
Keywords: general anesthesia, modified radical mastectomy, pectoral nerve I block, pectoral nerve II block
|How to cite this article:|
Alfy MO, Foad M. Pectoral nerve block for postoperative analgesia in breast cancer surgery. Sci J Al-Azhar Med Fac Girls 2020;4:71-7
|How to cite this URL:|
Alfy MO, Foad M. Pectoral nerve block for postoperative analgesia in breast cancer surgery. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 May 30];4:71-7. Available from: http://www.sjamf.eg.net/text.asp?2020/4/1/71/282866
| Introduction|| |
Breast cancer is the most common malignancy in women, and it is incidence continues to increase. Surgery is one of the mainstays of treatment of breast cancer, and modified radical mastectomy (MRM) is one of the standard treatments for multicentric disease or tumors with extensive coexistent ductal carcinoma in situ, where achieving a clear surgical margin becomes difficult with a segmental mastectomy. It is also indicated for individuals who are not candidates for radiation therapy, including those with active scleroderma, history of prior radiotherapy, and recurrent cases .
The growing increase in the number of breast surgeries as therapy for breast cancer and cosmetic purposes has resulted in an increased need for anesthetic techniques with improved pain reduction, safety, and fewer complications .
In breast surgery, acute postoperative pain from injured muscles and nerves is a consistent risk factor for chronic pain in association with its severity. Postoperative pain can seriously reduce the life quality, and acute pain can change into chronic pain syndrome. Management of acute postoperative pain is required for a better outcome and patients’ satisfaction. Regional techniques are regarded as the best choice to reduce postoperative pain .
Thoracic epidural and thoracic paravertebral techniques are widely used for anesthesia and postoperative pain management for breast cancer surgery, but not all anesthesiologists feel comfortable using such invasive techniques .
Blanco  have described pectoral nerve (PECS) I block aiming by injection an interfacial plane between the pectoralis major and pectoralis minor muscles targeting to block the lateral region of the breast to provide analgesia for breast surgery. Subsequently, with the inclusion of PECS I block as the first injection, a second injection at the interfascial plane between the pectoralis minor muscle and serratus anterior muscle (PECS II block) for analgesia of the axilla was reported to be good analgesia for breast surgery . This block is commonly performed using an in-line needling technique by ultrasound guidance, which is essential to identify the plane between the pectoralis major, minor muscles, and serratus anterior as well as the anatomical landmarks associated with them. Bashandy and Abbas  reported that PECS I and PECS II are able to reduce intraoperative fentanyl requirement, postoperative pain, morphine consumption, and postoperative nausea and vomiting (PONV) in patients undergoing breast cancer surgery; however, hematoma and local anesthetic toxicity are still the added risks of pneumothorax in PECS II block, which may be reduced by using ultrasound guidance and decreasing anesthetic concentration.
This current study prospectively aimed to compare PECS blocks in combination with general anesthesia versus general anesthesia alone in MRM surgery. The primary outcome was to measure visual analog scale (VAS) pain scores on a postoperative day, and the secondary outcomes were to measure perioperative opioid consumption, first rescue dose of analgesia, hemodynamics, and PONV.
| Patients and methods|| |
This randomized, prospective double-blind clinical study was carried at Al-Zahraa University Hospital, Cairo, Egypt, between March 2018 and March 2019. After obtaining approval from the hospital ethical committee, written informed consents were obtained from 60 female patients aged between 40 and 70 years, with American Society of Anesthesiologists status I or II, who were scheduled for breast surgeries. All selected patients presented with breast cancer which was diagnosed by clinical examination, ultrasound scan, and mammography and confirmed by histopathological examination of the biopsy taken.
American Society of Anesthesiologists physical status more than or equal to 3 (e.g. cardiac disease), allergy to the drugs used in the study, coagulation abnormality, history of alcohol or drug abuse, uncontrolled diabetes mellitus or hypertension, local infection at the site of block, BMI more than 30 kg/m2, and patients who refused to participate in the study were excluded.
The patients were randomly divided into two groups (using closed envelopes), and each one contained 30 patients. Control group received general anesthesia only. PECS group received general anesthesia plus PECS guided by ultrasound. Sonos cape A5 US device, manufactured by Sono Scape Medical Corp. (Shanghai, China), with liner array probe 5–10 MHz was used, with an imaging depth of 4–6 mm.
In the recovery unit, a 20-G cannula was inserted, and all patients were premedicated with midazolam 2 mg and metoclopramide 10 mg. In the operating room (OR), standard monitoring, including ECG, pulse oximetry, noninvasive blood pressure measurement, and capnography, was applied to the patient using Drager Infinity Vista XL monitor (Drager Medical System Inc., Telford, Pennsylvania, USA).
Pectoral nerve technique
After cleaning infraclavicular and axillary regions with chlorhexidine, the probe was placed below the lateral third of the clavicle. After recognition of the appropriate anatomical structures, the skin puncture point was infiltrated with 2% lignocaine and then the block was performed by using a 20-G Tuohy needle. The needle was advanced to the tissue plane between pectoralis major and pectoralis minor muscles, and injection of 10 ml of bupivacaine 0.25% after negative aspiration for blood (PECS I) near the pectoral muscles was deposited, and 20 ml of bupivacaine 0.25% was deposited at the level of the third rib between pectoralis minor and serratus anterior muscles (PECS II).
General anesthetic technique
Intravenous induction of general anesthesia in each group was performed by injection of fentanyl 1 μg/kg intravenous, propofol 2 mg/kg intravenous, and atracurium 0.5 mg/kg with the insertion of the endotracheal tube of suitable size and connection to a mechanical ventilator. The respiratory rate and tidal volume were adjusted to maintain the end-tidal CO2 within 10% variation from baseline values. Intravenous fluid therapy, transfusions, and other procedures followed the usual standards.
Maintenance of anesthesia was performed using Drager Fabius Plus Anesthetic Machine (Drager Medical System Inc.). Mechanical ventilation was initiated with a tidal volume of 8–10 ml/kg and an inspired oxygen fraction of 0.5 at a 3 l fresh gas flow, with isoflurane 1–2% and 0.1 mg/kg atracurium as top-up doses for muscle relaxation. Hemodynamic variables within 20% of baseline values were maintained, and maintenance of anesthetic depth between 40 and 60% was done by using bispectral index.
Modified radical mastectomy
The first step is the creation of skin flaps which are marked preoperatively. The skin is incised with a scalpel, and flaps are raised with either scalpel or electrocautery. The superior extent of dissection is the position where the superficial fascia fuses with the pectoralis fascia. The inferior extent of the dissection is the fusion of the breast fascia with that over the rectus abdominus. Electrocautery is used to divide the fascia over the pectoralis muscle and remove it with the breast.
The axilla is first entered by opening the clavipectoral fascia. Axillary vein is identified as it runs posterior to the pectoralis muscle, with careful blunt dissection and retraction inferiorly of the axillary contents. Once identified, carefully preserving its branches, the long thoracic nerve should be preserved. After that, the axillary contents are dissected off the thoracodorsal bundle superiorly and medially up to the level of the axillary vein and the specimen is handed off. Once the axillary dissection is completed, two drains are placed: one in the axilla and one anterior to the pectoralis muscle. The skin is then closed in an interrupted fashion.
At the end of the procedure, neostigmine was given to reverse neuromuscular block (0.05 mg/kg) with atropine (0.01 mg/kg intravenous). Endotracheal tube extubation was done, and then the patient was transferred to PACU. Patients were strongly advised that they should ask for analgesia if needed at any time after the surgery. If pain was not relieved by diclofenac sodium, morphine (5 mg) intramuscular was administered. Nausea and vomiting were treated using intramuscular metoclopramide 10 mg if PONV were present.
Intraoperative fentanyl was given to maintain heart rate (HR) and mean arterial pressure (MAP) values within 20% of the baseline. Hemodynamics (HR and MAP) were measured at baseline, at 15, 30, 45, 60, 75, and 90 min postinduction and 1, 3, 6, 12, and 24 h postoperatively. VAS scale at 0, 2, 4, 8, 12, and 24 h was used to assess the pain intensity. First rescue dose of analgesia, total morphine consumption to maintain VAS=4 or less, PONV score (0=no nausea and vomiting, 1=mild nausea, 2=severe nausea, 3=vomiting once, and 4=repeated vomiting) and complications related to the used procedure were recorded.
Sample size calculation
The sample size was calculated using PASS statistical program (NCSS, LLC The company is led by Dr. Jerry Hintze https://www.ncss.com/) for sample size calculation, version 19.0.3 and according to a study done by Bashandy and Abbas, who mentioned that the postoperative morphine consumption in the PECS group was lower in the first 12 h after surgery, with mean±SD of 2.8±1.2, than in the control group, with mean±SD of 4.15±1.8, with P value=0.040. According to the previous study and by adjusting the confidence interval to 95% type I error to 5, power of the test to 90% and the ratio between case and control to 1 : 1; the total sample size required for this study was found to be 54 cases, divided into two equal groups, with 27 patients in each group.
Data were collected, revised, coded, and entered the Statistical Package for Social Science (IBM SPSS), version 23 (IBM Corp., Armonk, New York, USA) The quantitative data were presented as mean, SDs, and ranges when parametric and median and interquartile range when data were nonparametric. The comparison between two groups regarding quantitative data with parametric distribution was done by using independent t test, whereas nonparametric distribution was done by using the Mann–Whitney test. The confidence interval was set to 95% and the margin of error accepted was set to 5%. So, the P value was considered significant at less than 0.05.
| Results|| |
Regarding demographic data, there was no statistically significant difference between two groups, as shown in [Table 1].
Regarding intraoperative fentanyl used to maintain systolic blood pressure between 100 and 140 mmHg, there was a highly statistically significant decrease in fentanyl requirement in the PECS group compared with the control group, as shown in [Figure 1].
|Figure 1 Intraoperative fentanyl requirement to maintain SBP between 100 and 140 mmHg. SBP, systolic blood pressure.|
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Regarding HR and MAP, there were significantly more stable HR and MAP at 15 min postinduction of general anesthesia till 6 h postoperatively, whereas there were nonsignificant differences between the two groups at baseline and 12 and 24 h postoperatively, as shown in [Figure 2] and [Figure 3].
|Figure 2 Comparison between the two groups regarding mean HR. HR, heart rate.|
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|Figure 3 Comparison between the two groups regarding MAP. MAP, mean arterial pressure.|
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Regarding VAS at 0, 2, 4, 8, 12, and 24 h postoperatively, there was a highly statistically significant decrease in VAS in PECS group compared with the control group at 2 and 12 h postoperative, whereas there was a statistically significant decrease in VAS in PECS group compared with the control group at 0, 4, 8, and 24 h postoperatively, as shown in [Table 2].
|Table 2 Comparison of visual analog scale at 0, 2, 4, 8, 12, and 24 h postoperatively [mean (range)]|
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Regarding first time of rescue dose of analgesia and total morphine consumption to maintain postoperative VAS=4 or less, there was a statistically significant increase in the first time of rescue dose of opioid in PECS group compared with the control group, as shown in [Figure 4], whereas there was a statistically significant decrease in total morphine consumption to maintain postoperative VAS=4 or less in PECS group compared with the control group, as shown in [Table 3].
|Figure 4 Comparison of the first time of rescue dose of analgesia between two groups.|
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Regarding PONV, there was a statistically significant decrease in the incidence of PONV in the PECS group compared with the control group, as shown in [Figure 5].
|Figure 5 Comparison of PONV between two groups. PONV, postoperative nausea and vomiting.|
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| Discussion|| |
Effective postoperative pain control can prevent the negative psychological and physiological consequences that can occur. Good postoperative pain control suppresses the stress response to surgery and reduces the need for opioids and can protect immunity. The severity of acute pain can be reduced using regional anesthesia techniques, and this leads to less chronic pain, and also PECS block effectively reduces the incidence of PONV and improves the patient’s quality of life .
Regarding intraoperative fentanyl used, postoperative first time of rescue dose of analgesia, and total morphine consumption to maintain postoperative VAS=4 or less, in the current study, there was a highly statistically significant decrease in intraoperative fentanyl used in PECS group compared with the control group. Regarding first time of rescue dose of analgesia and total morphine consumption to maintain postoperative VAS=4 or less, there was a statistically significant increase in first time of rescue dose of opioid in PECS group compared with the control group, whereas there was a statistically significant decrease in total morphine consumption to maintain postoperative VAS=4 or less in PECS group compared with the control group.
These results agree with Bashandy and Abbas , as they found that the mean intraoperative fentanyl consumption and the total amount of postoperative morphine were significantly lower in the PECS group than in the general anesthesia group. They reported that combined PECS block with general anesthesia produced excellent analgesia for breast surgery with axillary dissection.
Moreover, Kulhari et al  studied the effect of PECS block versus thoracic paravertebral block using ropivacaine 0.5% for postoperative analgesia after MRM, and found that the 24-h morphine consumption was decreased, and the duration of analgesia was significantly longer in patients who received the PECS. Moreover, Chakraborty et al. , in their study on a single injection of PECS block, showed that the pain-free duration extended to 24 h after PECS injection. These results were matched with Pedrosa  who found that the PECS block is an effective analgesic technique that allows decreased opioid consumption and its adverse effects, and he demonstrated that it should be considered as an alternative to conventional analgesia.
Moreover, Yuki et al.  studied PECS block versus general anesthesia in breast cancer surgery using 0.25% levobupivacaine, and they found that the mean fentanyl consumption was significantly lesser in the PECS group compared with the general anesthesia group, which was 280.37±44.38 and 304.91±60.35, respectively, and significantly lower postoperative analgesia in PECS group.
Moreover, Zhao et al. , in their meta-analysis, found that especially the PECS II block combined with general anesthesia was safe and effective option for analgesia in MRM compared with the control group, which was anesthetized by general anesthesia alone. PECS block was more effective in reducing intraoperative and postoperative opioid consumption (0–6 h) and incidence of PONV.
On the contrary, Morioka et al.  found no change in the intraoperative fentanyl consumption or the postoperative opioid supplement, and no statistically significant differences regarding PONV during their study on PECS combined with total intravenous anesthesia versus total intravenous anesthesia only for cancer breast. Moreover, they showed no difference in intraoperative fentanyl dose. Moreover, in PECS, the escape of the anterior divisions of intercostal nerves from the block made the pain to be the same over the sternum in all groups with the same opioid requirement.
Regarding VAS score, the current study shows there was a high statistically significant decrease in VAS in the PECS group compared with the control group at 2 and 12 h postoperatively, whereas there were statistically significant decreases in VAS in PECS group compared with the control group at 0, 4, 8, and 24 h postoperatively. These results matched with other studies ,,,,,,,, where they studied PECS block versus general anesthesia during breast cancer surgery, and they observed significantly lower VAS pain scores in the PECS blocks group at all postoperative periods.
Regarding HR and MAP, there was a statistically significant difference between the two studied groups at a time from 15 min postinduction till 6 h postoperatively.Moreover, Sopena-Zubiria et al. , in their study on the reconstructive breast surgery, demonstrated that the PECS has a good hemodynamic stability when added to the paravertebral block versus the thoracic paravertebral block alone. They consider it better than thoracic spinal anesthesia and PVB, where it provided satisfactory surgical anesthesia with prolonged postoperative analgesic period. Fujiwara et al.  found that PECS produces hemodynamic stability in their study on the comparison between intercostal nerve block versus PECS block effect on cardiac resynchronization therapy device. This can be explained by the fact that PECS is a nerve block that causes no sympathetic affection and no hemodynamic changes.
Regarding PONV; there was a statistically significant decrease in the incidence of PONV in the PECS group compared with the control group.
Other studies ,,,,,, examined MRM patients under general anesthesia with or without PECS blocks and found lower PONV scores in the PECS group.
| Conclusion|| |
PECS block has more advantages in MRM. It significantly reduces intraoperative fentanyl usage, decreases postoperative pain, decreases the requirement for postoperative supplemental analgesics, and decreases the incidence of PONV. Moreover, under ultrasonic guidance, it becomes a simple and easy-to-learn technique, with relatively no complications.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]