Modified Radical Mastectomy Surgery Research Articles

Comparative Study between Ultrasound Guided Modified Pectoral Nerve Block (PECSΙΙ) versus Ultrasound Guided Serratus Anterior Muscle Plane Block for Analgesia Following Modified Radical Mastectomy

Abstract Background Modified pectoral nerve (PECSII) and serratus plane blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This comparative study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus block in patients undergoing modified radical mastectomy (MRM) for breast cancer. Objective To evaluate and compare the effect of both PECS II block versus and Serratus anterior block in patients undergoing modified radical mastectomy surgery. Patients and Methods The duration of analgesia and effect on hemodynamics parameters were evaluated. Moreover, undesirable side effects were studied. Thirty-six patients were randomly allocated into two equal groups (18 patients): group (A) and group (B). Group (A): received a PECSII block with 30 mL of bupivacaine 0.25%. Group (B): received a serratus anterior plane block (SAPB) using the same volume of 30 ml bupivacaine 0.25%. All patients were clinically assessed and routine preoperative investigations were done: CBC, Coagulation profile, liver function tests, kidney function tests, fasting blood sugar and ECG. The initial vital data were measured after applying the standard monitoring including pulse oximetry, non-invasive blood pressure and ECG. Results This study demonstrated that PECSII and serratus blocks have comparable analgesic properties in patients undergoing modified radical mastectomy. Both blocks were comparable in postoperative pain intensity, postoperative morphine consumption, and intraoperative fentanyl requirement. The two blocks were comparable in hemodynamics, and VAS score. The two blocks were associated with hemodynamic stability, and high satisfaction scores. The absence of major complications characterizes both blocks. Conclusion This study confirms that PECSII and serratus blocks provide similar adequate analgesia following modified radical mastectomy.

Comparative Study Between Ultrasound Guided Serratus Anterior Plane Block versus Thoracic Erector Spinae Plane Block as Postoperative Pain Management in Modified Radical Mastectomy

Abstract 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 (MRM) is one of the standard treatments for multi-centric disease or tumors with extensive coexistent ductal carcinoma in situ, where achieving a clear surgical margin becomes difficult with a segmental mastectomy. Objective This Study compared between Serratus Anterior Plane block and Thoracic Erector spinae block as efficacy of postoperative analgesia in Modified Radical Mastectomy. Patients and Methods This was a prospective controlled double blinded randomized clinical study that was conducted at Ain Shams University hospitals, Cairo, Egypt on Adult female patients undergoing modified radical mastectomy and were randomly assigned into two equal groups by computer generated method: Group A (control group): patients received general anaesthesia followed by Serratus Anterior plane block using only 20 ml 0.25% Bupivacaine (safety dose 3mg/kg). Group B(study group): patients received general anaesthesia followed by Thoracic Erector Spinae block using only 20ml bupivacaine 0.25 %. (safety dose 3mg /kg). Results In this study, we found that the postoperative VAS scores were better in Group SAP at 2nd, 4th, 6th and 12th hr as compared to group TES. The incidence of PONV and the requirement of Ondansetron were found to be similar in both groups. None of the patients in either group developed technique-related complications like hemodynamic instability, intravascular injection, pneumothorax, local anaesthetic systemic toxicity, and adverse effects like pruritus and respiratory depression. Conclusion USG-SAPB was effective and safe technique which provides better pain relief compared with the USG-TESP and reduced post operative opioid consumption. Therefore, the SAP can be used safely for post operative analgesia for patients undergoing MRM surgery to avoid the risk of developing chronic post mastectomy pain which reduces quality of life.

Comparative Study between Modified Pectoral Nerve Block versus Serratus Block for Analgesia For Modified Radical Mastectomy

Abstract Background One of the main objectives of anesthesia is to alleviate the patient’s pain and agony, by ensuring the performance of surgical procedures without any discomfort. Elimination of postoperative pain is indispensable due to the central, peripheral and immunological stress response to tissue injury. So there is a need for extended analgesia without any side effects to achieve this goal. Objective To assess the analgesic efficiency and safety of both Modified Pectoral Nerve Block versus Serratus Block in cases of modified radical mastectomy (MRM). The duration of analgesia and effect on hemodynamic parameters were evaluated. Moreover, undesirable side effects were studied. Patients and Methods The purpose of this study was to evaluate the effect of both PECS II block versus and Serratus anterior block in patients undergoing modified radical mastectomy surgery. The duration of analgesia and effect on hemodynamics parameters were evaluated. Moreover, undesirable side effects were studied. forty patients were randomly allocated into two equal groups (20 patients): group (A) and group (B). Group (A): received a PECSII block with 30 mL of bupivacaine 0.25%. Group(B): received a serratus anterior plane block (SAPB) using the same volume of 30 ml bupivacaine 0.25%. Results This study demonstrated that PECSII and serratus blocks have comparable analgesic properties in patients undergoing modified radical mastectomy. Both blocks were associated with reduced postoperative pain intensity and morphine consumption, intraoperative fentanyl requirement, and prolonged analgesia. The two blocks were associated with hemodynamic stability and absence of major complications characterizes both blocks. Conclusion This study confirms that PECSII and serratus blocks provide similarly adequate analgesia following modified radical mastectomy.

Unilateral modified radical mastectomy with thoracic epidural anesthesia and serratus anterior plane block under dexmedetomidine sedation in a patient with multiple comorbidities: a case report

Anesthesia management in patients with multiple comorbidities is extremely challenging for the anesthesiologist. We aimed to present anesthesia management with dexmedetomidine sedation accompanied by thoracic epidural anesthesia and serratus anterior plane block in a 59-year-old high-risk patient with multiple comorbidities who was planned for modified radical mastectomy. We suggest that serratus anterior plane block can be used combined with thoracic epidural anesthesia as an effective, safe, and feasible method for hemodynamic stability in intraoperative and postoperative pain control in patients undergoing modified radical mastectomy surgery and in reducing the need for postoperative analgesic use and postoperative complications.

Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery.

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. Eighty-one female patients aged 18-70years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30ml 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 30ml 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 24h postoperatively. Both the RIB (58.3 ± 22.8mg) and PECS (68.3 ± 21.2mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6h 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). 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 24h and improved the quality of recovery in the early period.

Original research: Dexmedetomidine versus ketamine in erector spinae plane block for postoperative analgesia following modified radical mastectomy: A prospective randomized controlled blinded study

ABSTRACT Background A significant postoperative pain has been documented in numerous breast cancer cases following modified radical mastectomy (MRM). We evaluated the effectiveness of dexmedetomidine (DEX) versus ketamine as adjuvants to local anaesthetic in erector spinae plane block (ESPB) in MRM. Methods In this randomized controlled trial, 75 women with breast cancer scheduled for MRM were included. All patients underwent ESPB with 30 ml 0.25% bupivacaine and randomized into three equal groups: group A, ESPB group; group B: received 1 µg/kg DEX with the ESPB; and group C: given 0.5 mg/kg Ketamine with the block. Results Compared with group A, VAS score at rest as well as movement were lower considerably in groups B and C (p < 0.05) at 6 h, 12 h, and 24 h. Group B had lower VAS scores at rest at 12 h and 24 h and during movement at 6 h, 12 h, and 24 h (p < 0.05) than group C. In comparison to A Group; B and C Groups required considerably less time to rescue analgesia and consumed significantly fewer total opioids (p < 0.05 and p < 0.001, respectively). In addition, total number of patients who required additional analgesia was markedly reduced in groups B and C compared to group A ;(p < 0.05). Conclusion In MRM surgery, the postoperative opioids consumption and VAS values were lower in both groups DEX and ketamine as an adjuvant to bupivacaine which enhanced the analgesic profile and prolonged ESPB duration compared to ESPB alone, with DEX being superior to ketamine.

Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer: study protocol for a randomised controlled trial

BackgroundA single injection of local anaesthetic (LA) in the erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy (MRM) surgery, but the duration of analgesia is affected by the duration of the LA. The aim of this study is to investigate the effect of continuous ESPB on acute and chronic pain and inflammatory response after MRM surgery.MethodsIn this prospective, randomised, controlled trial, we will recruit 160 patients, aged 18–80 years, scheduled for elective MRM surgery under general anaesthesia. They will be randomly assigned to two groups: a continuous ESPB group (group E) and a sham block group (group C). Both groups of patients will have a nerve block (group C pretended to puncture) and an indwelling catheter fixed prior to surgery. Electronic pumps containing LA are shielded. The primary outcome is the total consumption of analgesic agents. The secondary outcomes include the levels of inflammation-related cytokines; the occurrence of chronic pain (post-mastectomy pain syndrome, PMPS); static and dynamic pain scores at 2, 6, 12, 24 and 48 h postoperatively; and post-operative and post-puncture adverse reactions.DiscussionAnalgesia after MRM surgery is important and chronic pain can develop when acute pain is prolonged, but the analgesic effect of a nerve block with a single injection of LA is limited by the duration of drug action. The aim of this trial is to investigate whether continuous ESPB can reduce acute pain after MRM surgery and reduce the incidence of chronic pain (PMPS), with fewer postoperative analgesic drug-related complications and less inflammatory response. Continuous ESPB and up to 12 months of follow-up are two innovations of this trial.Trial registrationChinese Clinical Trial Registry (https://www.chictr.org.cn/) ChiCTR2200061935. Registered on 11 July 2022. This trial is a prospective registry with the following registry names: Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer.

Efficacy of Erector Spinae Plane Block in Modified Radical Mastectomy for Postoperative Analgesia: A Randomised Controlled Study

Introduction: The Erector Spinae Plane Block (ESPB) is a recently introduced Ultrasound (US)-guided interfascial plane block commonly used for treating thoracic neuropathic pain. Although ESPB has been used for pain control after Modified Radical Mastectomy (MRM), which is a frequently performed operation nowadays, its efficacy compared to other methods of pain control is yet to be established. Aim: To evaluate the effectiveness of ESPB in controlling acute postoperative pain after MRM surgery. Materials and Methods: A total of 64 adult females aged between 18-60 years, with American Society of Anaesthesiologists (ASA) physical status I and II, scheduled to undergo elective MRM, were enrolled in the present randomised, double-blinded, controlled study conducted at Department of Anaesthesiology and Critical Care, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India over a period of nine months (from March 2021 to November 2021). They were randomly assigned to two groups, with 32 patients in each group. Group A (n=32) received general anaesthesia only, while Group B (n=32) received US-guided ESPB in addition to general anaesthesia. Postoperative Visual Analogue Scale (VAS) scores, total intra and postoperative analgesic requirements for the first 24 hours, and duration of postoperative analgesia were recorded for each patient. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 24.0 software. Mean and Standard Deviation (SD) were used to express data for numerical variables, while count and percentages were used for categorical variables. Results: Demographic characteristics (age, weight), ASA status, and mean duration of surgery were similar between the groups. The duration of postoperative analgesia was significantly (p&lt;0.05) prolonged in Group B patients (584.1±89.1 minutes) compared to Group A patients (78.0±53.1 minutes). Intra and postoperative analgesic requirements were significantly lower in Group B (fentanyl 87.0±16.8 mcg, tramadol 68.3±35.9 mg) compared to Group A patients (fentanyl 94.5±26.7 mcg, tramadol 158.3±32.3 mg). The postoperative VAS score was more favourable in Group B than in Group A (1.1±0.4 vs. 4.1±0.8 at rest). Conclusion: The US-guided ESPB is a simple and easy procedure that provides prolonged duration of postoperative analgesia with reduced overall analgesic requirement in the postoperative period after MRM surgery. Therefore, it can be concluded that ESPB is an effective method for controlling acute postoperative pain after MRM surgery.

Correlation between Estrogen Receptor, Progesterone Receptor, and Ki-67 Expression Levels with Neoadjuvant AC-T Chemotherapy Response in Triple Positive Breast Cancer (TPBC) Patients after Modified Radical Mastectomy (MRM) at Prof. Dr. I.G.N.G. Ngoerah General Hospital

Background: Triple Positive Breast Cancer (TPBC), a subtype of breast cancer expressing ER, PR, and HER-2, has unique biological characteristics that influence therapy response. Neoadjuvant AC-T chemotherapy is commonly used for TPBC; however, the correlation between ER, PR, and Ki-67 expression levels and therapy response remains unclear. TPBC has a lower pathological complete response (pCR) rate compared to other subtypes, but a low pCR does not always indicate a poor prognosis. This study aimed to evaluate the correlation between ER, PR, and Ki-67 expression levels and the response to neoadjuvant AC-T chemotherapy in TPBC patients to support more effective and safer treatment strategies. Methods: This analytical observational study used a cross-sectional design conducted at Prof. Dr. I.G.N.G Ngoerah General Hospital, Denpasar, from June 2022 to June 2023. The target population was TPBC patients who underwent neoadjuvant AC-T chemotherapy and MRM surgery. Samples were collected using consecutive sampling. Data were analyzed using descriptive statistics, ROC curve analysis to determine variable cut-off points, and Chi-Square tests to assess relationships between variables. Results: ROC analysis showed a cut-off point for ER at 17.5% (AUC 0.506, p=0.950), PR at 25% (AUC 0.521, p=0.815), and Ki-67 at 35% (AUC 0.465, p=0.700). Chi-square tests revealed no significant correlation between high expression of ER (p=0.717), PR (p=0.505), or Ki-67 (p=0.970) and chemotherapy response. Conclusions: ER, PR, and Ki-67 expression levels do not significantly correlate with the response to neoadjuvant AC-T chemotherapy in TPBC patients.

Ultrasound-assisted Upper Thoracic Epidural Anaesthesia in Awake Breast Surgeries: A Case Series

Carcinoma of the breast is a leading cause of hospitalisation in elderly women and the most common surgery performed in Surgical Oncology and General Surgery Departments. Traditionally, General Anaesthesia (GA) was used for patients undergoing modified radical mastectomy. However, GA is not an ideal choice for patients with restrictive pulmonary diseases, obesity, or Chronic Obstructive Pulmonary Disease (COPD), as it is associated with increased intraoperative and postoperative complications. Regional anaesthesia is a suitable alternative, as it has the advantages of reduced sympathetic stimulation, no airway manipulation, and avoids polypharmacy, thereby reducing the hospital stay. A series of 10 female patients were presented, who were scheduled for modified radical mastectomy surgery under ultrasound-assisted thoracic epidural anaesthesia, and the patients were awake and conscious throughout the surgery. The ultrasound-assisted upper thoracic epidural was performed with a 100% success rate, and the mean procedure time taken was 238.5 seconds (ultrasound examination plus needle placement). Out of the 10 patients, one patient had two needle punctures. The needle redirections were absent in three patients, two times in three patients, and one time in four patients. Except for one patient, the epidural was successfully placed on the first attempt. Patient comfort was assessed based on the Modified Comfort Scale, with Grade-1 in five patients, Grade-2 in four patients and Grade-3 in one patient. No complications such as dural puncture or bloody tap were reported. In patients scheduled for modified radical mastectomy, performing an upper thoracic epidural using a landmark-guided technique is challenging, as the thoracic spines are very acutely angulated (T3-T6). Therefore, the ultrasound-assisted thoracic epidural technique is a safe and effective bedside tool that can be used to identify the epidural space without any side effects for the patients.

Effect of preoperative ultrasound-guided thoracic interfacial plane block versus preoperative thoracic erector spinae plane block on acute and chronic pain after modified radical mastectomy: A randomized controlled trial

ABSTRACT Background More than 50% of individuals who have breast surgery have acute postoperative pain, and 8% among those patients endure persistent severe pain. The purpose of this study was to evaluate the efficiency of ultrasound-guided thoracic inter-fascial plane block (US-guided TIFPB) and ultrasound guided erector spinae plane block (US-guided ESPB) on acute and chronic pain following modified radical mastectomy (MRM) surgeries. Methods 90 female participants who were hospitalized for unilateral MRM surgery underwent this prospective randomized controlled trial. Patients were split into three equal groups at random: Group I: received preoperative TIFPB, group II: received preoperative ESPB, group III: received preoperative sham block (control group). Results VAS was considerably lower in group I at 12 h (P1 = 0.029) and when group III is compared with groups I and II at 2, 4, 6, 12, 18 and 24 h (P < 0.05). First analgesic requires was greatly delayed in time and total morphine consumption was significantly decreased compared to group III in groups I and II (P < 0.001) and was insignificantly different between both groups I and II. Chronic pain 3, 6 months postoperative was markedly decreased in comparison to group III in groups I and II (P < 0.05). Conclusions TIFPB and ESPB were comparable, both were superior to control in terms of lower intraoperative fentanyl consumption, pain score, first analgesic requirement onset is delayed, lower total consumption of morphine, chronic pain 3 and 6 months postoperatively. TIFPB showed a lower pain score at 12 hr. postoperatively compared to ESPB.

Effectiveness of Ultrasonography Guided Pectoral Nerve Block for Post-Operative Analgesia in Modified Radical Mastectomy

Background: Modified radical mastectomy surgery results in high morbidity and patient dissatisfaction due to incomplete postoperative pain relief. The most frequent malignancy among women worldwide is breast cancer. Objectives: The aim of this study was to assess effectiveness of ultrasonography-guided Pectoral nerve block for postoperative analgesia after Modified radical mastectomy. Methods: This descriptive type of cross-sectional study was carried out in the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine in collaboration with department of surgery, Dhaka Medical College &amp; Hospital, Dhaka during July 2021 to June 2022. A total of 28 patients were participate in this study. Purposive sampling technique was followed. After taking consent and matching eligibility criteria, data were collected from patients using the predesigned structured questionnaire by interview. Statistical analyses of the results were obtained by using window-based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-25). Results: Mean age of patient was 54.7 ± 7.3 years majority belonged to 50-59 years of age (39.2%). Maximum patient had ASA Class II (60.7%). In case of staging of the cancer 39.2% were in stage I and 60.8% were in stage II. Average duration of surgery was 119.4 ± 14.2 minutes. The mean VAS score of the patients at 2nd hrs was 0.52±0.2, at 4th hrs was 0.65±0.3, at 6th hrs was 1.12±0.6, at 8th hrs was 2.31±1.35, at 10th hrs was 3.34±1.45, at 12th hrs was 4.83±1.40, at 14th hrs was 2.24±1.30, at 16th hrs, at 18th hrs 2.74±1.65, at 20th hrs was 4.48±1.70 and at 24th hrs was 2.28±1.80. the mean 1st analgesic demand (hour) was 12.2±2.1 and the Total opioid consumption (mg) was 165.7±18.2. Conclusion: For postoperative pain management after breast surgery, various procedures have been employed, including local anesthetic infiltration, intercostal nerve block, thoracic epidural block, and paravertebral block. They might not be appropriate ..

Comparative study between ultrasound guided modified pectoral nerve block versus erector spinae block in breast surgeries-prospective randomised comparative study

Background: Breast cancer is the most common cancer in women, comprising approximately 25% of all cases. Failure to provide effective pain control is associated with poor quality of recovery &amp; chronic postsurgical pain after breast surgery. According to a recently published PROSPECT guideline, pectoral nerve (PECS) blocks seem to be an effective alternative to PVB for postsurgical pain management in breast surgery. In order to relieve post-operative pain in patients undergoing MRM, in this study we compared the efficacy of modified pectoral nerve block versus erector spinae plane block for breast cancer surgeries. Methods: A comparative study was conducted among 80 female patients of age 25-65 years scheduled for modified radical mastectomy surgery with ASA class I and II after obtaining approval from ethical committee. Written informed consent was obtained and research process were explained to the patients. They were randomly allocated into two groups of 40 each. Group 1: was assigned to receive 0.2% Ropivacaine 25ml for Erector spinae block and Group 2: Was assigned to receive 0.2% ropivacaine 25 ml for modified pectoral nerve block, p value &lt;0.05 was considered statistically significant. Results: In patients receiving modified pectoral nerve block (PEC 2) there was considerably lesser opioid consumption, Ionger duration of analgesia and lesser postoperative pain score as compared to patients receiving erector spinae block (ESP) for modified radical mastectomy surgeries. Conclusions: Modified Pectoral nerve block is a potential analgesic technique in breast surgeries since it has less perioperative opioid consumption, proIonged duration of anaIgesia, Iesser postoperative pain score when compared to Erector Spinae block.

Efficacy of dexmedetomidine as an adjuvant with ropivacaine in USG guided erector spinae plane block for modified radical mastectomy surgery- prospective randomized double blind controlled study

Background and Aims: Modified radical mastectomy (MRM) is associated with considerable acute postoperative pain and even chronic persistent pain. Erector spinae plane block (ESPB) is interfascial block for thoracic analgesia. This study was planned to evaluate efficacy of dexmedetomidine as adjuvant with ropivacaine in ESPB for postoperative analgesia in MRM surgery. Materials and Methods: In this prospective randomized double-blind controlled study, 60 American Society of Anesthesiologists Grade I and II female patients, aged 18–60 years scheduled for MRM surgery under general anesthesia were randomly allocated into Group R and RD to receive ultrasound (USG)-guided ESPB with 20 ml 0.375% ropivacaine and 1 μg/kg dexmedetomidine added to 20 ml 0.375% ropivacaine, respectively. Visual Analog Score (VAS) was recorded at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperatively. Duration of analgesia together with total number and amount of analgesic drug required was recorded in first 24 h postoperatively. Patient's satisfaction score was recorded on 10-point scale. Chi-square test, t-test, and Wilcoxon signed-rank test were applied where deemed appropriate. P &lt;0.05 was considered statistically significant. Results: VAS score was less in Group RD at all measured time points postoperatively. Duration of analgesia was prolonged in Group RD (683.00 ± 83.99 min vs. 620.63 ± 70.42 min). Total number and amount of intravenous diclofenac (rescue analgesic) was lower in Group RD (1.13 ± 0.57 vs. 1.46 ± 0.57, 85.00 ± 42.85 vs. 110.00 ± 42.85). Patients in group RD were better satisfied with their anesthesia experience (8 [8–9] vs. 8 [7–8], P = 0.00194). Group RD demonstrated a lower heart rate, systolic blood pressure, diastolic blood pressure, and mean blood pressure intraoperatively. Conclusion: Dexmedetomidine as an adjuvant to ropivacaine in USG-guided ESPB for MRM surgery leads to lower postoperative pain scores, prolongs postoperative analgesia, reduces postoperative rescue analgesics requirements, and provides better hemodynamic stability and good patient satisfaction.

Comparison of Analgesic Effect of Clonidine as an Adjuvant with Different Concentration of Ropivacaine (0.35% and 0.2%) in Thoracic Paravertebral Block among Modified Radical Mastectomy Patients: A Randomised Double Blinded Clinical Study

Introduction: Thoracic Paravertebral Block (TPVB) appears promising for reduction of postoperative pain in Modified Radical Mastectomy (MRM). Various combinations of local anaesthetics and adjuvants have been tried in TPVB but search for an ideal combination is still on. Aim: To evaluate analgesic efficacy of clonidine (1 µg/kg) as adjuvant with different concentrations of ropivacaine (0.35%, 0.2%) for TPVB in MRM surgery. Materials and Methods: This randomised double blind comparative clinical study was carried out in a tertiary care centre in Southern Rajasthan from January 2019 to March 2020, clinical study, 120 American Society of Anaesthesiologists (ASA) grade I, II patients aged 18-60 years female patients undergoing MRM surgery were randomised into three groupsRP, RC and LDRC to receive 0.35% Ropivacaine 19 mL, 0.35% Ropivacaine 19 ml+Clonidine (1 µg/kg) and 0.2% Ropivacaine 19 ml+Clonidine(1 µg/kg) diluted upto total 20 ml with normal saline, respectively. TPVB was performed at T4 level as single injection followed by administration of general endotracheal anaesthesia. The primary outcome measured was duration of analgesia. Secondary outcomes measured included consumption of rescue analgesic, Visual analog scale and perioperative haemodynamic parameters. Quantitative and qualitative data were analysed using Analysis of Variance (ANOVA) and Chi-square test respectively. p&lt;0.05 was considered statistically significant. Results: Mean duration of analgesia was prolonged in clonidine groups RC and LDRC (811.5±110.99 and 753±119.76 min, respectively) as compared to group RP (400.125±108.13 min), although no statistically significant difference was noted between group RC and LDRC. Similar observations were noted when total dose of rescue analgesic in group RC (82.50±7.21 mg) and LDRC (99.38±35.57 mg) was compared to group RP (142.50±53.169 mg) as well as when total number of rescue analgesic doses in group RC (1.10±0.496) and group LDRC (1.32±0.474) were compared to group RP (1.92±0.694). Visual Analogue Scale (VAS) was noted at rest, cough, movement at 0, 4, 8, 12, 24 hours and showed a statistically significant difference between ropivacaine group RP and ropivacaine clonidine groups. Conclusion: Addition of clonidine to ropivacaine in TPVB during breast cancer surgery results in lower pain scores, prolong duration of analgesia and reduce postoperative requirement of rescue analgesics. Both lower (0.2%) and higher (0.35%) concentrations of ropivacaine provide equally effective postoperative analgesia.

Active Drainage versus Passive Drainage after Modified Radical Mastectomy in Patients with Breast Carcinoma: A Randomised Controlled Trial

Introduction: Postoperative seroma formation is a common complication following Modified Radical Mastectomy (MRM), with an incidence ranging from 15-60%. There is a hypothesis that the negative pressure created by the suction drain used in MRM opens the damaged capillaries, preventing them from spontaneously closing and thereby increasing postoperative secretions. Aim: To compare active suction drains with passive drains in MRM in terms of postoperative outcomes. Materials and Methods: A randomised controlled trial with two arms, consisting of 15 patients in each arm, was conducted from November 2018 to March 2020 at the Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital in New Delhi. Patients diagnosed with localised breast carcinoma and scheduled for MRM were invited to participate. Pregnant females, patients with metastatic disease, those lost to follow-up, recurrent breast cancer patients, and those taking anticoagulants and antiplatelet agents were excluded from the study. The outcomes measured were drain output and duration of hospital stay, and postoperative morbidity, including flap necrosis, surgical site infection, seroma, and volume of seroma aspiration. The data acquired was analysed using the Statistical Package for Social Sciences (SPSS) version 21.0. Quantitative variables were compared using the Independent t-test and Mann-Whitney test as appropriate. Nominal categorical data was compared using the Chi-square or Fisher’s-exact test as appropriate. Results: Drain output was higher in the active group than in the passive group, but there was no significant difference in the average daily drain output and the average total output (652 mL versus 540 mL), except for the first two postoperative days. There was no statistically significant difference between the two groups in terms of hospital stay (6.67 days and 6.27 days), duration of drains in situ (6.67 days and 6.27 days), flap necrosis (13.3% vs. 13.3%), seroma formation (26.67% vs. 20%), and surgical site infection (26.67% vs. 20%). Conclusion: The use of suction in drains during MRM surgery is not compulsory and can save costs in resourcepoor settings. However, larger sample size studies with multicentre participation should be undertaken before making any recommendations.

Effectiveness of Ultrasonography Guided Pectoral Nerve Block and Paravertebral Block For Post-Operative Analgesia in Modified Radical Mastectomy

Background: Incomplete alleviation of postoperative pain in modified radical mastectomy surgery causes significant morbidity and patient dissatisfaction. General anaesthesia with postoperative NSAIDs and opioids commonly used technique for postoperative analgesia after breast surgeries. Along with regional anaesthesia various peripheral nerve blocks are performed to manage this problem. Paravertebral block and pectoral nerve block are exercised widely to reduce postoperative pain after modified radical mastectomy.Objective: The aim of this study is to assess the effectiveness of ultrasonography guided paravertebral block and pectoral nerve block for postoperative analgesia for modified radical mastectomy.Methods: This randomized control trial was conducted at Dhaka Medical College &amp; Hospital, Dhaka from July 2020 to June 2021. Total 60 patients, scheduled for modified radical mastectomy and randomly divided into two groups having 30 patients in each (Group-A= paravertebral block and Group-B =pectoral nerve block). Among them, 5 patients were excluded from the study due to block failure (three in group A and two in group B). So, finally, data were calculated for the 55 patients (27 patients in group A and 28 in group B). Heart rate, systolic blood pressure, mean arterial pressure, the time of first analgesic demand and the total amount of analgesic consumption in the first 24 hours by VAS were recorded and compared between two groups during postoperative period. Statistical analysis was done by SPSS version 25. Chi-square test was done for qualitative variables and Student’s t-test was done for quantitative variables. P &lt; 0.05 was considered statistically significant.Results: The demographic profile were well matched between two groups (P &gt; 0.05). The mean VAS score was significantly lower in pectoral nerve block as compared to the paravertebral block at all-time intervals except at 12 hours and 20 hours (P &lt; 0.05). Patients with pectoral nerve block had significantly late 1st analgesic demand (12.2 ± 2.1 hours’ vs 8.3 ± 1.8 hours) (P &lt; 0.05) and significantly less total opioid consumption (165.7 ± 18.2mg vs 255.6 ± 15.8mg) (P &lt; 0.05) compared to patients with paravertebral block. Post-operative side effects were noted significantly more in patients with paravertebral block compared to pectoral nerve block.Conclusion: Pectoral nerve block performed in patients scheduled for modified radical mastectomy results in better pain control, late first analgesic demand and less postoperative opioid consumption in the first 24 hours than paravertebral block.

Effectiveness of Erector Spinae Plane Block for Postoperative Analgesia in Modified Radical Mastectomy

Postoperative pain control in breast cancer surgery has become one of the most important goals for anesthesiologists. Several techniques have been trialed for providing postoperative analgesia after breast surgery. This randomized control study was designed to evaluate the postoperative analgesic effect of ultrasound-guided erector spinae plane (US-guided ESP) block for modified radical mastectomy surgery. To evaluate the postoperative analgesic effect of pectoral nerves block and erector spinae plane block for modified radical mastectomy surgery. This prospective, randomized, controlled trial was conducted at the Department of Anaesthesia, Analgesia, Palliative &amp; Intensive Care Medicine in Dhaka Medical College and Hospital. A total 46 patients who were to undergo modified radical mastectomy, fulfilling selection criteria were included in the study following confirmation of the informed written consent and randomly divided into two groups- where each group include 23 Patients. Group A received ultrasound guided ESP and group B received ultrasound guided PECS block. All patients of both groups received GA after confirmation of block. All relevant information including demographic criteria, medical history, clinical evaluation during and after performance of block were collected. All patients were observed peri-operatively and data were recorded into the preformed questionnaires form. Finally, data was analyzed by SPSS version 22.0. Mean age of study population was 52.07±7.08 years with majority in age group 50-59 years. No significant difference was noted between patient’s characteristics, duration of surgery and heart rate and mean arterial pressure of patient during and after operation between two groups (p&gt;0.05). The mean VAS score was significantly low in ESP block as compared to the PECS block at all-time interval (p&lt;0.05) except at 12 hours. Patients with ESP block had significantly late demand of 1st analgesic (12.13±2.45 hours vs 8.89±3.35 hours) (p&lt;0.05) and significantly less total opioid consumption (5.17±0.57 mg vs 10.18±1.82 mg) (p&lt;0.05) compared to patients with PECS block. Post-operative complication was noted significantly higher among patients with PECS block compared to ESP block. These findings from our study depict ESP block performed in patients scheduled for MRM (modified radical mastectomy) results in better pain control and less postoperative opioid consumption in the first 24 hours than PECS block.&#x0D; CBMJ 2022 July: vol. 11 no. 02 P: 86-95

Subclavian Artery Thrombosis Post Modified Radical Mastectomy Surgery - A Rare Case Report

Subclavian artery thrombosis is a relatively rare and unheard complication postmodified radical mastectomy (MRM) surgery and it is still not reported in the literature. We report a case of a 55-year-old female who underwent MRM for Stage II left ductal carcinoma of breast with level 2 lymph node involvement in a private hospital. She developed ischemic pain in the left upper limb on postoperative day 3. She came to JNMCH and was referred to us and initial imaging with computed tomography angiography revealed occlusion from the origin of the subclavian to axillary artery. We discuss the management of the aforementioned condition in our setup and would also discuss the steps needed to avoid the same in the future.

Inflammatory Breast Cancer: The Secretome of HCMV+ Tumor-Associated Macrophages Enhances Proliferation, Invasion, Colony Formation, and Expression of Cancer Stem Cell Markers.

Inflammatory breast cancer (IBC) is a highly aggressive phenotype of breast cancer that is characterized by a high incidence early metastasis. We previously reported a significant association of human cytomegalovirus (HCMV) DNA in the carcinoma tissues of IBC patients but not in the adjacent normal tissues. HCMV-infected macrophages serve as “mobile vectors” for spreading and disseminating virus to different organs, and IBC cancer tissues are highly infiltrated by tumor-associated macrophages (TAMs) that enhance IBC progression and promote breast cancer stem cell (BCSC)-like properties. Therefore, there is a need to understand the role of HCMV-infected TAMs in IBC progression. The present study aimed to test the effect of the secretome (cytokines and secreted factors) of TAMs derived from HCMV+ monocytes isolated from IBC specimens on the proliferation, invasion, and BCSC abundance when tested on the IBC cell line SUM149. HCMV+ monocytes were isolated from IBC patients during modified radical mastectomy surgery and tested in vitro for polarization into TAMs using the secretome of SUM149 cells. MTT, clonogenic, invasion, real-time PCR arrays, PathScan Intracellular Signaling array, and cytokine arrays were used to characterize the secretome of HCMV+ TAMs for their effect on the progression of SUM149 cells. The results showed that the secretome of HCMV+ TAMs expressed high levels of IL-6, IL-8, and MCP-1 cytokines compared to HCMV- TAMs. In addition, the secretome of HCMV+ TAMs induced the proliferation, invasion, colony formation, and expression of BCSC-related genes in SUM149 cells compared to mock untreated cells. In addition, the secretome of HCMV+ TAMs activated the phosphorylation of intracellular signaling molecules p-STAT3, p-AMPKα, p-PRAS40, and p-SAPK/JNK in SUM149 cells. In conclusion, this study shows that the secretome of HCMV+ TAMs enhances the proliferation, invasion, colony formation, and BCSC properties by activating the phosphorylation of p-STAT3, p-AMPKα, p-PRAS40, and p-SAPK/JNK intracellular signaling molecules in IBC cells.