Unilateral Modified Radical Mastectomy Research Articles

A randomised comparative study of erector spinae plane block versus low-dose ketamine-dexmedetomidine intravenous infusion as intraoperative opioid-free analgesia for modified radical mastectomy

Background and Aims: Opioid-sparing analgesia for acute postoperative pain after breast cancer surgery is crucial due to opioid-related side effects. The utilisation of erector spinae plane block and low-dose intravenous ketamine-dexmedetomidine are widely recognised as non-opioid analgesic methodologies. The objective of this study was to conduct a randomised trial to examine the analgesic efficacy of both approaches while minimising the use of opioids. Methods: Seventy-two female patients scheduled for unilateral modified radical mastectomy were recruited. They were allocated randomly to Group ESPB, which received ipsilateral ultrasound-guided erector spinae plane block by 20 mL bupivacaine 0.5% at the level of T5 after induction of general anaesthesia, and Group Ket-Dex, which received intravenous (IV) bolus 0.25 mg/kg of ketamine and 0.5 µg/kg of dexmedetomidine, followed by an IV infusion of 0.25 mg/kg of ketamine and 0.3 µg/kg of dexmedetomidine per hour. Total postoperative morphine consumption (24 h) was the primary outcome. The secondary outcomes were pain scores over 24 hours during rest, duration of analgesia, isoflurane consumption, time to awakening, postoperative nausea and vomiting (PONV), and postoperative serum cortisol level. Results: The postoperative morphine consumption over 24-hour in Group ESPB was 3.26 mg (0–6.74) versus 2.35 mg (2.08–4.88) in Group Ket-Dex (P = 0.046). Group Ket-Dex had lower pain scores at rest, longer analgesia duration, longer awakening time, and lower postoperative serum cortisol levels. Conclusion: Intravenous low-dose ketamine-dexmedetomidine infusion intraoperatively with inhalational-based general anaesthesia provides superior opioid-sparing analgesia to that of ESPB in patients undergoing unilateral non-reconstructive modified radical mastectomy, with less postoperative opioid consumption and stress response.

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.

Effects of a single subanesthetic dose of esketamine on postoperative subthreshold depressive symptoms in patients undergoing unilateral modified radical mastectomy: a randomised, controlled, double-blind trial

BackgroundBreast cancer is the most common malignant tumor in females worldwide. During disease development, breast cancer patients suffer anxious and depressed, which may lead to worse quality of life or even higher mortality. Esketamine has been regarded as an antidepressant in breast cancer patients with mild or moderate depression. Here, we wonder whether the administration of esketamine could reduce the postoperative depressive symptom score of breast cancer patients who have no preoperative depression.MethodsA total of 64 patients treated with unilateral modified radical mastectomy were randomly divided into an experimental group (esketamine group, Group E) and a control group (Group C), with 32 cases in each one. After anesthesia induction, Group C received 0.2 ml/kg of normal saline intravenously and Group E was administered 0.2 mg/kg intravenous esketamine. The primary outcome was the Patient Health Questionnaire-9 (PHQ-9) scores. The secondary outcomes included the Visual Analogue Scale (VAS) scores for pain, inflammatory markers, perioperative-related indicators, and the incidence of postoperative delirium, nausea and vomiting.ResultsThe PHQ-9 score on postoperative day (POD) 1 in Group E declined from the preoperative level, while the score in Group C was higher than before, and the former was far lower than the latter (P = 0.047). There is no statistically significant difference in PHQ-9 scores between Group E and Group C on POD 3, 7, and 30. Moreover, the postoperative leukocyte level of Group E was higher than that of Group C, and the difference was statistically significant (P = 0.030).ConclusionsA single subanesthetic dose of esketamine can result in lower postoperative score on subthreshold depressive symptoms compared to the Group C on POD 1, without increasing the occurrence of postoperative adverse reactions.Trial registrationRegistration number: Chinese Clinical Trial Registry ChiCTR2200057028. Date of registration: 26/02/2022.

An Intraoperative Sub-Anesthetic Dose of Esketamine on Postoperative Depressive Symptoms in Perimenopausal Women with Breast Cancer Undergoing Modified Radical Mastectomy: Protocol for a Randomized, Triple-Blinded, Controlled Trial.

Depressive symptoms are common among perimenopausal women with breast cancer having modified radical mastectomy. Esketamine exerts antidepressant effects. This study aims to assess whether an intraoperative sub-anesthetic dose of esketamine prevents postoperative depressive symptoms in these patients. In this randomized, triple-blinded, placebo-controlled trial, we will enroll 130 perimenopausal women (aged 45-60 years) with breast cancer undergoing unilateral modified radical mastectomy. Patients will be randomly assigned with a 1:1 ratio to receive either esketamine (0.25 mg/kg i.v.) or normal saline after anesthesia induction and before skin incision. The primary outcome is the incidence of depressive symptoms at day 30 postoperatively, assessed using the Beck's Depression Inventory (BDI). Secondary outcomes include incidence of depressive symptoms and BDI scores at day 1, 3, and 180 postoperatively, anxiety symptoms and scores at day 1, 3, 30, and 180 postoperatively, pain intensity and quality of recovery at day 1 and 2 postoperatively, nausea and vomiting within 48 hours postoperatively, length of postoperative hospital stay, and cancer-specific outcomes. Data will be analyzed in the modified intention-to-treat population. This is the first trial to evaluate the effects of a sub-anesthetic dose of esketamine on depressive symptoms in perimenopausal women after modified radical mastectomy. The results of this study will help to improve their mental health and recovery after breast cancer surgery. Chinese Clinical Trial Registry (ChiCTR2200064348).

EFFICACY OF THORACIC SEGMENTAL SPINAL ANESTHESIA ALONG WITH UNILATERAL ERECTOR SPINAE BLOCK IN PATIENTS UNDERGOING UNILATERAL MODIFIED RADICAL MASTECTOMY AND AXILLARY DISSECTION: A NOVEL MULTICENTRIC STUDY

Objectives: The aim of the study was to find out the efficacy of thoracic segmental spinal anesthesia combined with unilateral erector spinae block in patients undergoing unilateral modified radical mastectomy and axillary lymph node dissection Methods: This was a prospective cohort study in which 40 patients with carcinoma breast undergoing modified radical mastectomy with axillary dissection under thoracic segmental spinal anesthesia combined with unilateral erector spinae block were included on the basis of a predefined inclusion and exclusion criteria. Erector spinae plane block was given at T5 level and thoracic spinal anesthesia was then given at T5–T6 level in the same position by median or paramedian technique. Patients were assessed for severity of pain by visual analog scale score till 24 h of surgery. Results: The mean age of studied cases was found to be 44.12±10.04 years. Mean weight of studied cases was 54.38±9.8 kg, whereas mean duration of surgery was found to be 98.24±16.86 min. The most common American Society of Anesthesiologists (ASA) grade to which patients belonged was found to be ASA III (55%) followed by ASA II (30%) and ASA I (15%). Eleven patients required rescue analgesia within first 24 h after surgery and mean doses of rescue analgesia in 1st 24 h after surgery was found to be 0.92±0.48. Four (10%) patients developed hypotension, whereas three (7.5%) patients had bradycardia. However, all these 7 (17.5%) had transient bradycardia or hypotension which could be managed by IV Atropine or IV mephentermine and fluid bolus. Conclusion: Thoracic segmental spinal anesthesia combined with unilateral erector spinae block is an excellent option for patients undergoing modified radical mastectomy with axillary dissection.

Ultrasound-guided serratus anterior block versus instillation of local anaesthetic through surgical drain in modified radical mastectomy: A randomized controlled study

ABSTRACT Background The primary outcome measure of this study was to compare ultrasound-guided serratus anterior block versus instillation of local anesthetic through the surgical drain in modified radical mastectomy patients as regards the duration of analgesia between the two techniques. Material and methods This prospective, randomized, double-blinded study was conducted on 162 female patients aged 25–50 years, ASA 1, ASA 2, selected for elective unilateral modified radical mastectomy in the Main University Hospital. Group SABP (n = 81) received 20 ml bupivacaine 0.5% in the plan between serratus anterior and latissimus dorsi muscles. Group LA (n = 81) received 40 ml bupivacaine 0.25%, 20 ml in each surgical drain (axillary and chest wall drain). Results The results of the study revealed that the duration of analgesia lasted for 20.8 hr in the SAPB group, while it was 8.14 hourshr in the LA group (P-value ˂0.001). In most postoperative periods, the SAPB group had lower VAS scores at rest and with movement of the ipsilateral arm compared to the LA group. The overall dose and frequency of the consumed rescue analgesic over the first 24 hr in the postoperative period were significantly lower in the SAPB group than in the second group (P-value <0.001). The SAPB group had higher satisfaction scores than the LA group (P-value <0.001). Conclusion It was concluded that the SAPB technique showed superiority over the anesthetic instillation method in controlling acute post-mastectomy pain with a longer duration of analgesia, more patient satisfaction, and less rescue analgesics were consumed.

Effects of Ultrasound-Guided Stellate Ganglion Block on Postoperative Quality of Recovery in Patients Undergoing Breast Cancer Surgery: A Randomized Controlled Clinical Trial.

Surgery has been the primary treatment for breast cancer. However, instant postoperative complications, such as sleep disorder and pain, dramatically impair early postoperative quality of recovery, resulting in more extended hospital stays and higher costs. Recent clinical trials indicated that stellate ganglion block (SGB) could prolong sleep time and improve sleep quality in breast cancer survivors. Moreover, during the perioperative period, SGB enhanced the recovery of gastrointestinal functions in patients with laparoscopic colorectal cancer surgery and thoracolumbar spinal surgery. Furthermore, perioperative SGB decreased intraoperative requirements for anesthetics and analgesics in patients with complex regional pain syndrome. However, information is scarce regarding the effects of SGB on postoperative quality recovery in patients with breast cancer surgery. Therefore, we investigated the effects of SGB on the postoperative quality of recovery of patients undergoing breast cancer surgery. Sixty patients who underwent an elective unilateral modified radical mastectomy were randomized into two 30-patient groups that received either an ultrasound-guided right-sided SGB with 6 ml 0.25% ropivacaine (SGB group) or no block (control group). The primary outcome was the quality of postoperative recovery 24 hours after surgery, assessed with a Chinese version of the 40-item Quality of Recovery (QoR-40) questionnaire. Secondary outcomes were intraoperative requirements of propofol and opioids, rest pain at two, four, eight, and 24 hours after surgery, patient satisfaction score, and the incidence of postoperative abdominal distension. At 24 hours after surgery, global QoR-40 scores were higher in the SGB group than in the control group. Besides, in the SGB group, patients needed less propofol, had a lower incidence of postoperative abdominal bloating, and had higher satisfaction scores. Ultrasound-guided SGB could improve the quality of postoperative recovery in patients undergoing breast cancer surgery by less intraoperatively need for propofol and better postoperative recovery of sleep and gastrointestinal function.

The Analgesic Effect of Dexamethasone and Magnesium Sulphate (MgSO4) as an adjuvant to 0.25% Bupivacaine in ultrasound guided Pectoral Nerve Block (PEC Block) for unilateral Modified Radical Mastectomy: A Comparative Study

Background: Postoperative pain following unilateral modified radical mastectomy (MRM) has been managed with Pectoral nerve block (PEC block). Several initiatives are ongoing to get the effective and safe way of prolongation analgesic effect postoperatively. Therefore, many types of adjuvants are adding to the local anaesthetic agents to prolong their analgesic effect. In this study either dexamethasone or magnesium sulphate (MgSO4) has added as an adjuvant to 0.25% bupivacaine in pectoral plane block (PEC block) for unilateral modified radical mastectomy. Here we observed which of the adjuvant would prolong the analgesic effect of 0.25% bupivacaine. Methods: This randomized controlled trial was conducted at the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine, Dhaka Medical College following approval of the ethical committee. These patients were selected from the department of General Surgery, Dhaka Medical College during preanaesthetic checkup periods. Total 50 patients were scheduled for modified radical mastectomy and divided into Group A and Group B (each group contain 25 patients). The patients of the both groups were given pectoral plane block under ultrasound guide with 0.25% bupivacaine. The patients of Group A received magnasium sulphate 150 mg and Group B received dexamethasone 10 mg as an adjuvant to 0.25% bupivacaine. Pectoral nerve block was performed before induction of general anaesthesia and onset of sensory block was assessed among the both groups. All patients were observed peri-operatively and data were recorded into the data collection form. Finally, data was analyzed by SPSS version 22. Observation and Results: Socio-demographic profile were similar among the both groups (p&gt;0.05). No significant difference was noted in terms of ASA score and BMI (p&gt;0.05). Mean duration of the analgesia (min) and time requirement of rescue analgesic therapy were significantly higher in dexamethasone group (p&lt;0.05) than MgSO4 group. Post-operative requirement of pethidine (72.5±8.5vs 55.2±5.4 mg; p&lt;.045) was also higher in MgSO4 group. Side effects profile like nausea and vomiting also significantly small in dexamethasone (4%) group than people received MgSO4 group (20%) (p&lt;0.05). Conclusion: Use of dexamethasone in comparison to MgSO4 as an adjuvant to bupivacaine could prolong analgesia in postoperative period for pectoral plane block in unilateral modified radical mastectomy. CBMJ 2022 January: vol. 11 no. 01 P: 4-13

Erector Spinae Plane Block Versus PECS Block Type II for Breast Surgery: A Randomized Controlled Trial.

BackgroundRegional anesthetic techniques are the primary analgesic techniques in breast cancer surgery. Novel techniques include the pectoralis (PECS) block and the erector spinae plane (ESP) block.ObjectivesThis study compared the analgesic efficacy of ultrasound-guided ESP and PECS-II blocks in patients undergoing unilateral modified radical mastectomy (MRM).MethodsThe current prospective randomized controlled trial investigated 60 females scheduled for unilateral MRM under general anesthesia. The participants were randomized into two groups, namely a single-shot ESP block (n = 30) and a PECS-II block (n = 30). The ESP block was conducted at the level T4 using an in-plane approach. A volume of 20 ml of bupivacaine 0.25% was administered in both blocks. The outcome measures were total morphine consumption, analgesia duration, postoperative pain intensity, and nausea and vomiting.ResultsMore ESP participants required rescue morphine analgesia than those in the PECS group (P = 0.028). The ESP group showed significantly higher total morphine consumption (P = 0.005) and a shorter time to request analgesia (P = 0.003). Pain intensity was higher in the ESP group 1, 2, and 6 hours after the surgery.ConclusionsThe PECS-II block is more effective in postoperative pain control after breast cancer surgery than the ESP block. It also prolongs the duration of analgesia and reduces the need for morphine 24 hours after the surgery.

Comparative Study between Ultrasound Guided Erector Spinae Plane Block versus Paravertebral Block for Postoperative Pain Relief in Patients Undergoing Unilateral Modified Radical Mastectomy

Comparative Study between Ultrasound Guided Erector Spinae Plane Block versus Paravertebral Block for Postoperative Pain Relief in Patients Undergoing Unilateral Modified Radical Mastectomy

Analgesic efficacy and opioid sparing effect of erector spinae plane block in oncologic breast surgery: An observational study

Background/Aim: Erector spinae plane block (ESPB) is a fascial plane block technique suitable for perioperative analgesia. This study aimed to evaluate the value of ESPB performed under ultrasound guidance and with ANI (Analgesia Nociception Index) monitoring in terms of intraoperative opioid need and postoperative pain management, in patients undergoing oncological breast surgery. Methods: This prospective case-control study includes forty-two female breast cancer patients who underwent unilateral modified radical mastectomy with axillary lymph node dissection. Patients were allocated to receive (ESPB group) or not receive (controls) ultrasound guided ESPB before anesthesia induction based on patient preference, and the groups were compared in terms of total intraoperative opioid consumption (with the guidance of ANI) and postoperative pain. Visual analogue scores (VAS) were obtained during the 12-hour postoperative follow-up. Results: Total intraoperative remifentanil dose required was significantly lower in the ESPB group when compared to controls (361.9 (108.3) vs. 1560.0 (4), P

Abstract No. : ABS1591: Effect of erector spinae block and PECS block on quality of recovery and analgesia after modified radical mastectomy

Background and Aims:Breast cancer is the most common malignancy in women ; modified radical mastectomy is one of the standard treatments.This study compared the effect of erector spinae block and pectoralis(PECS) block on quality of recovery and analgesia after modified radical mastectomyMethods:The present randomised controlled double-blind study was conducted on 90 patients undergoing unilateral modified radical mastectomy for breast cancer. The patients were randomised into group-I (PECS block 20ml 0.25% bupivacaine, n=30), group-II (erector spinae block 20ml 0.25% bupivacaine, n=30) and group-III (control group, n=30). Along with clinical anddemographical data, the requirement of the first dose of rescue analgesia, total rescue analgesic consumption, visual analogue scale(VAS) scores and Quality of Recovery(QoR) -40 scoreswere compared. Anaesthesia and surgical interventions were done as per standard protocol.Results:Mean first rescue analgesic requirement was significantly delayed in group-I followed by group-II compared to controls . Mean total rescue analgesic consumption was much lower in group-I and group-II as compared to group-III and the difference was statistically significant (p<0.0001)(figure 1). Mean VAS scores were also much lower in group-I followed by group-II as compared to group-III at different follow-ups, and difference was statistically significant. The global QoR-40 at 24 hours showed significantly better outcomes in group-1(table 1)Figure 1Global QoR-40 between the groupsTable 1Postoperative tramadol requirementAnalgesic requirementGroup B (n=30)Group C (n=30) P Time for 1st need of tramadol (h)8.10±1.480.7±0.38<0.001Total tramadol consumption (mg)68±48.55210±52.65<0.0001Total numberof patients requiring tramadol (%) 24 h10 (33.33%)30 (100%)<0.0001Table 1Quality of Recovery(QoR) -40 scores between the groupsGlobal QoR-40 (0-200)Group I (n=30)Group-II (n=30)Group-III (n=30) P Pre-operative186.63±7.78185.53±6.73186.34±7.56P=0.8360At 24 h183.64±6.36179.68±6.38171.37±6.88P<0.001* P t=1.63, P=0.1086t=3.455, P=0.0010*t=8.021, P<0.001*Conclusion:Both PECS and ESP block can be used efficaciously for providing analgesia in modified radical mastectomy for breast cancer. However, PECS shows better outcomes.

Comparison of the Efficacy of Ultrasound-guided Pectoral versus Erector Spinae Plane Blocks for Postoperative Analgesia in Patients undergoing Modified Radical Mastectomy: A Randomised Controlled Trial

Introduction: Postmastectomy pain is more common following carcinoma breast surgery. Preventive analgesia for breast carcinoma includes administration of local infiltration or regional anaesthesia in the form of a paravertebral block, epidural, pectoral nerve block or intercostal block. Interfascial blocks, such as ultrasound guided pectoral nerve (PECS II) and Erector Spinae Plane (ESP) block have been shown to provide effective analgesia for mastectomy surgeries. Aim: To compare the postoperative analgesic efficacy of PECSII block and ESP block following mastectomy surgeries. Materials and Methods: The present study was a doubleblinded randomised controlled study. Patients scheduled for an elective unilateral modified radical mastectomy surgery of age 18-70 years, American Society of Anaesthesiologists (ASA) physical status I-II, were endrolled in the study. Sixty patients (ASA I-II) were divided into two groups. (30 in the PECS II group and 30 in the ESP group). The patients received respective blocks under ultrasound guidance after general anaesthesia. The primary outcome measured was the time of first request analgesia between groups. The secondary outcomes were postoperative Numeric Rating Scale (NRS) at eight different time-points (0.5, 1st, 2nd, 4th, 6th, 8th 12th and 24th hour) and intraoperative fentanyl requirement and haemodynamics (heart rate and mean arterial pressure). Total postoperative intravenous paracetamol consumption and rescue analgesic requirement in the first 24 hours postoperatively were noted. Statistical analysis was conducted by using Statistical Package for the Social Sciences (SPSS) version 20.0. Pearson’s Chi-square test was performed to compare ratios, and categorical variables were compared using Fisher’s exact test. A p-value value &lt;0.05 was taken as statistically significant. Results: The time of first request analgesia was prolonged and significant in ESP block (255.5±48.76 minutes) than PEC II (197.5±31.35 minutes) (p=0.000347). In the postoperative ward, NRS scores at the 30th min, first and second hour were significantly lower in ESP block than PECS II group (2.3±0.4 vs. 5.2±0.8; 3.2±0.4 vs. 4.4±0.3, 3.7±0.4 vs. 5.2±0.4); p=0.041 p=0.047, p=0.037 respectively. From the second postoperative hour to the end of the observation period, there were no significant changes in NRS scores among groups. Postoperative paracetamol consumption was significantly higher in PECS II than ESPB (1.25±0.5 grams vs 2.33±1.2 grams, p&lt;0.043824). There was no change in intraoperative fentanyl consumption and haemodynamics between groups. Conclusion: ESP block had better pain control, reduced postoperative pain scores and rescue analgesia than PECS II when given as preventive analgesia in mastectomy surgeries.

The role of physiotherapy treatment in arm lymphoedema associated with breast cancer

Ipsilateral arm lymphoedema is the most frequent long-term complication due to breast cancer surgery, chemo- and radiotherapy, affecting approximately 40% of women treated for this condition. We conducted a retrospective study to assess the efficiency of physiotherapy procedures in reducing arm lymphoedema in women who underwent an exhaustive treatment plan for breast cancer. The study included 32 patients out of the 641 with breast cancer, who were treated by the same multidisciplinary team at the “Prof. Dr. Alexandru Trestioreanu” Institute of Oncology in Bucharest. They underwent unilateral modified radical mastectomy with axillary clearance between 1 January 2016 and 31 December 2019 due to developing ipsilateral arm lymphoedema, stage 2. Of the 18 patients who received individual counselling and education, manual lymph drainage and compressive bandage, 10 (55.5%) decreased arm lymphoedema from stage 2 to 1 after 3 months of treatment. Of the 14 patients who associated these procedures and also benefitted from additional individual physiotherapy including stretching exercises (for the levator scapulae, trapezius, pectoralis major and minor) and progressive active and action-assisted shoulder exercises, 11 (78.5%) reduced arm lymphoedema to stage 1 and regained upper arm mobility and sensitivity. Early initiation of physiotherapy after modified radical mastectomy with axillary lymph node dissection, along with patient education, is associated with a higher regression rate of arm lymphoedema compared to only patient education and awareness. The treatment response rate was 85.7% in patients benefitting from lymphatic drainage, compressive bandage and an individual physiotherapy plan compared to 55.5% in patients only benefitting from lymphatic drainage and compressive bandage.

Patient's proprioceptive remnants in nipple reconstruction planning.

The aim of this study is to demonstrate that for patients undergoing mastectomy the use of the proprioceptive memory represents a valid method to identify the perfect position of the nipple, which will be reconstructed on an operated breast. Fifty-one patients undergoing breast reconstruction after unilateral Modified Radical Mastectomy or unilateral Skin Sparing Mastectomy were included in the study. All patients were asked to identify, while keeping their eyes closed, the mammary segment where they perceived their nipples, both on the reconstructed breast mound and on the contralateral breast. Sternal Notch-to-nipple distance (SN), Nipple-to-inframammary Fold distance (NF), Midclavicular line-to-nipple distance (CN), the distance from the nipple to the chest Midline (NM), Anterior Axillary line-to-nipple distance (ZN) were measured on both breasts. The ideal position of the nipple to be reconstructed was evaluated using a geometric method based on the Pythagorean Theorem. A statistically significant correlation emerges between the distances measured from the anatomical landmarks of the chest to the point coinciding with the patient's perception of the nipple on the reconstructed breast, and the distances measured from the same chest landmarks to the nipple on the contralateral native breast and to the nipple placed in the ideal position assessed with the geometric method. The patient's proprioceptive memory of the nipple position can be useful to identify the exact place to reconstruct the nipple in breast reconstruction.

EFFECTIVENESS OF ULTRASOUND-GUIDED MODIFIED PECTORAL NERVE BLOCK (PECS II) FOR POST-OPERATIVE PAIN RELIEF AFTER MODIFIED RADICAL MASTECTOMY (MRM)

Objective: To find the effectiveness of ultrasound guided modified pectoral nerve block (PECS II) versus conventional analgesics for post-operative pain relief in women undergoing modified radical mastectomy.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Department of Anaesthesia, Pak Emirates Military Hospital Rawalpindi Pakistan, from May 2018 to Oct 2019.&#x0D; Methodology: A total of 74 adult female patients scheduled for elective unilateral modified radical mastectomy under general anaesthesia were randomized into two groups, pectoral nerve block II (P) group (n=37) and control (C) group (n=37). An ultrasound-guided pectoral nerve block II block was performed using 30 ml of 0.25% Bupivacaine in pectoral nerve block II group after induction of general anaesthesia. In control group (C), patients received only general anaesthesia. Primary outcome measure was opioid consumption in first 24 hours, and the secondary outcome was pain at the breast and axillary region measured using the numerical rating scale (NRS) in first 24 hours at fixed intervals after surgery. Patient satisfaction was evaluated upon discharge using a 4-point scale.&#x0D; Results: Nalbuphine consumption was significantly reduced in pectoral nerve block group as compared to control group. Patients in pectoral nerve block II group experienced much less pain because their numerical rating scale was lower than the control group in postoperative period. Patient satisfaction was found to be high in pectoral nerve block II group.&#x0D; Conclusion: The pectoral nerve block II block is a simple block which provides excellent analgesia for modified radical mastectomy. It can be used for balanced anaesthesia.......

Serratus anterior plane block reduces the prevalence of chronic postsurgical pain after modified radical mastectomy: A randomized controlled trial

Study objectiveTo determine whether ultrasound-guided serratus anterior plane block (SAPB) is associated with decreased prevalence of chronic postsurgical pain (CPSP) after modified radical mastectomy. DesignRandomized, double-blind, placebo-controlled study. SettingUniversity hospital. PatientsWe enrolled 198 patients aged 18–65 years with American Society of Anesthesiologists physical status I to II, undergoing unilateral modified radical mastectomy. InterventionsPatients were randomly allocated to receive SAPB with 30 ml of 0.5% ropivacaine (SAPB group) or 0.9% normal saline (Control group). MeasurementsThe primary outcome was the prevalence of CPSP three months after surgery. Secondary outcomes were area under the curve of the numeric rating scale pain scores over 24 h, postoperative 24-h morphine consumption, quality of recovery, length of post-anesthesia care unit stay, postoperative nausea and vomiting, dizziness, SAPB-related adverse events, the prevalence of CPSP at six months, and pain-related function at three and six months. Main resultsPreoperative SAPB with 0.5% ropivacaine reduced the prevalence of CPSP at three postoperative months from 46/89 (51.7%) to 22/90 (25.6%), relative risk (95% confidence interval): 0.47 (0.31–0.72), P < 0.001. The prevalence of CPSP was reduced at six months from 37/89 (41.6%) to 17/90 (18.9%), relative risk (95% confidence interval): 0.72 (0.58–0.88), P = 0.001. Moreover, SAPB decreased the area under the curve of the numeric rating scale pain scores over 24 h, shortened the length of post-anesthesia care unit stay, reduced postoperative 24-h morphine consumption and the occurrence of postoperative nausea and vomiting, and improved quality of recovery and patient satisfaction, with P < 0.05 for all. No SAPB-related complications occurred. ConclusionsPreoperative SAPB with ropivacaine improved acute postoperative analgesia and quality of recovery and decreased the prevalence of CPSP at three and six months after modified radical mastectomy.

Application of a new serratus anterior plane block in modified radical mastectomy under ultrasound guidance: A prospective, randomized controlled trial

Study objectivesPost-operative pain is a significant concern following modified radical mastectomy in breast cancer patients. The serratus anterior plane block has recently been described as an effective technique for post-operative analgesia of modified radical mastectomy. The purpose of this study was to evaluate the analgesic efficacy and safety of a new serratus anterior plane (SAP) block for post-operative pain of mastectomy. DesignA randomized controlled trial. SettingSingle university teaching hospital, from October 2019 to April 2020. PatientsEighty-seven female breast cancer patients aged 30–81 years scheduled for unilateral modified radical mastectomy. InterventionsParticipants were randomly allocated to receive either general anesthesia plus SAP block (SAP block group, n = 43) or general anesthesia alone (Control group, n = 44). A single injection of 20 ml of 0.5% ropivacaine was administered into fascial plane between the pectoralis major and the serratus anterior in SAP block group. In the Control group, no block intervention was applied. MeasurementsThe primary outcome measure of the study was the VAS pain scores at different time-points (1, 6, 12, 24, 48 h) after modified radical mastectomy whereas the secondary outcome measures were the consumption of opioid analgesics. Main resultsBreast cancer patients in SAP block group had lower VAS pain scores compared with the Control group during the early post-operative period (1 h and 6 h after modified radical mastectomy), both at rest and with movement. In addition, the consumption of propofol was similar in two groups (P = 0.406), and the consumption of sufentanil and remifentanil in SAP block group were significantly lower than that of Control group (P = 0.000 and P = 0.000, respectively). ConclusionsSAP block significantly attenuated post-operative pain and decreased opioids consumption in breast cancer patients undergoing modified radical mastectomy. Trial registrationThis trial is registered in the Chinese Clinical Trial Registry (ChiCTR1900026989).

Evaluation of Latissimus Dorsi Muscle Atrophy via Computed Tomography in Patients with Breast Cancer After Axillary Lymph Node Dissection

This study aimed to evaluate atrophy of the latissimus dorsi muscle (LDM) via computed tomography (CT) in patients who underwent mastectomy and axillary lymph node dissection (ALND). Secondary objectives were to investigate the relationship between the number of lymph nodes and muscle atrophy and to evaluate a possible correlation of muscle atrophy with the time interval between surgery and CT. The data of 125 patients who underwent unilateral modified radical mastectomy and ALND were reviewed retrospectively. The thickness and density of LDM were assessed using thorax computed tomography. The non-surgical side served as the control for each patient. The number of lymph nodes removed at ALND and the time from surgery to CT scan were also reported and evaluated for correlation with muscle atrophy. The mean thickness and density of the LDM were statistically significantly lower on the surgical side compared to the non-surgical side (p 0.05). The thickness and density of the LDM were seen to be decreased due to surgery although preservation of the nervus thoracodorsalis was defined in the surgery report. Intraoperative injury of the nerve during surgery may present more commonly than expected and affect muscle atrophy. In addition, the immobility of patients with breast cancer due to pain and swelling may also cause muscle atrophy.

Pectoral Nerves Blocks for Post-Operative Analgesia after BreastCancer Surgery

AbstractBackground: Breast cancer is the world's most commoncancer among women, surgey is one of the main treatmentsfor this disease. Several ways to prevent post mastectomypain were used, one of them is the pectoral nerves blocks (PECs Blocks).Aim of Study: Study aimed to evaluate the efficacy ofultrasound guided Pectoral neves blocks for post-operativeanalgesia after modified radical mastectomy surgery.Patients and Methods: The study was carried out on fourtyadult female patients, who were scheduled for elective unilat-eral modified radical mastectomy, they were randomly assignedto two groups, Pectoral nerves block (Pecs) group, includedtwenty patients who received preoperative Pecs blocks (com-bination of Pecs I and Pecs II) followed by general anesthesia,and control group which included twenty patients who receivedgeneral anesthesia only.Results: It was found that VAS score was statisticallysignificant higher in control group than Pecs group. Therewas a significant difference concerning the total dose ofnalbuphine consumption in 24 hours post-operative betweenboth groups which is lower in Pecs group than in controlgroup. There was a higher satisfaction scores were obtainedin Pecs group than in control group with no detected compli-cations other than PONV.Conclusion: The Pecs blocks produce excellent analgesiawhen combined with general anesthesia for modified radicalmastectomy surgery. They are simple, easy-to-learn techniques,having easily identifiable landmarks based on good anatomicaland ultrasound knowledge, making them an excellent alterna-tive to the conventional thoracic paravertebral and neuroaxialblocks for breast surgeries. Also ultrasound guided Pecs blockssignificantly reduces VAS.