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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 203-209

Effect of a pectoral nerve block as a part of enhanced recovery after a mastectomy


Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission03-Mar-2021
Date of Decision04-May-2021
Date of Acceptance15-May-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Ibrahim M. Ibrahim Helal
Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_55_21

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  Abstract 


Objectives
This study was carried out to assess the efficacy of a pectoral nerve block in female patients undergoing a mastectomy.
Background
Pain after breast surgery could be managed in many ways such as by opioid administration. However, there has been an increasing trend toward the application of nerve block techniques to decrease opioid consumption. We carried out this research to evaluate the efficacy of a pectoral nerve block in female patients undergoing a mastectomy.
Patients and methods
This prospective randomized study included 50 patients preparing for breast cancer surgery who were allocated into two equal groups: group A included 25 patients who received a sham pectoral nerve block and group B included the remaining patients who received a pectoral nerve block. The postoperative visual analog scale was our primary outcome, whereas intraoperative and postoperative opioid consumption, nausea, and vomiting were the secondary outcomes.
Results
Despite the absence of significant differences between the two groups in patient and operation characteristics, group B showed a significant reduction in intraoperative fentanyl consumption, together with total doses of postoperative paracetamol and nalbuphine and lower visual analog scale values compared with the controls during the first 10 h after surgery. The first analgesic request was delayed in group B, which also showed a significant decrease in postoperative nausea and vomiting. Patient satisfaction was significantly better in the same group.
Conclusion
Pectoral nerve block is a safe and effective technique that offers effective pain relief after breast surgery. It leads to decreased analgesic consumption and increased patient satisfaction.

Keywords: enhanced recovery, mastectomy, pectoral block, sham block


How to cite this article:
Alsisi AA, Eskandar AM, El-Sayed Rageh TM, Helal IM. Effect of a pectoral nerve block as a part of enhanced recovery after a mastectomy. Menoufia Med J 2022;35:203-9

How to cite this URL:
Alsisi AA, Eskandar AM, El-Sayed Rageh TM, Helal IM. Effect of a pectoral nerve block as a part of enhanced recovery after a mastectomy. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:203-9. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/203/343129




  Introduction Top


Breast cancer is the most common malignancy encountered in females as it accounts for about 22.9% of female cancers worldwide and about 37.7% of all female cancers in Egypt. Breast cancer carries an unfavorable prognosis, with a 29% mortality and a 3.7: 1 incidence to mortality ratio [1]. Surgical resection, via modified radical mastectomy or conservative breast surgery, is the mainstay treatment modality for such lesions [2].

Postoperative pain control is one of the most common problems encountered by patients undergoing breast surgery. A previous survey has reported that pain is the major concern of all patients before undergoing surgery [3]. Acute postoperative pain, when uncontrolled, can exacerbate the surgical stress response, which may adversely affect the metabolic, endocrine, inflammatory, and immune status [4].

Proper management of acute postoperative pain has a positive impact on postoperative outcomes including shorter hospital stay, decreased healthcare costs, and improved patient satisfaction [5]. Moreover, although chronic postoperative pain is multifactorial, its incidence could be decreased by proper management of pain in the acute postoperative setting [6].

Multiple methods are used to control pain after breast surgery including oral and intravenous pharmacological analgesics, along with more invasive techniques that utilize local anesthesia for pain control, such as local anesthetic infiltration, thoracic epidural anesthesia, intercostal block, pectoral nerve block, and paravertebral block [7].

In 2011, a pectoral interfascial block or a pectoral nerve block I (Pecs I) was first reported by Blanco [8], and they described the injection of the anesthetic agent into the space between both pectoralis muscles at which pectoral nerves are located. In 2012, pectoral nerve block II (Pecs II block) was also described, and it involves administration of additional anesthesia into the intercostobrachial, long thoracic, and third-sixth intercostal nerves to provide more pain relief, especially in patients undergoing axillary dissection. It involves Pecs I in addition to a second injection between the pectoralis minor and serratus anterior muscles [9].

The application of such a technique would help to decrease postoperative analgesic requirements after the operation, which in turn will lead to decreased anticipated side effects associated with opioid and nonsteroidal drug administration [10]. This study was carried out to assess the efficacy and safety of supplementing general anesthesia with a pectoral nerve block in female patients undergoing a mastectomy.


  Patients and methods Top


This is a prospective randomized study that was carried out over 1 year, from December 2018 to December 2019, on adult patients undergoing breast surgery at Menoufia University Hospitals. Sample size calculation was based on the assumption that the difference in the visual analog scale (VAS) between the two groups would be 25% according to previous studies; setting the alpha to 0.05 and beta to 20%, we calculate that an appropriate group size would be 20 patients in each group, to be increased to 25 patients to overcome dropouts.

We included patients between 20 and 70 years of age with American Society of Anesthesiologists score I or II, diagnosed with breast cancer and preparing for mastectomy (modified radical mastectomy or conservative breast surgery). However, patients with a history of allergy to one of the study medications were excluded.

After approval of the study by the local ethical committee of Menoufia University, written informed consent was obtained from all patients. The study included 50 patients who were randomly divided by closed-envelope methods into two equal groups: group A included 25 patients who received a sham pectoral nerve block in addition to general anesthesia and group B included 25 patients who received a pectoral nerve block in addition to general anesthesia.

For the included patients, proper patient evaluation was performed including proper assessment of history and physical examination, along with routine laboratory and radiological investigations. Patients were recommended to fast for 6 h before the operation.

On the day of the operation, patients were transferred to the operation theater, where anesthesia was administered by propofol 2 mg/kg (Diprivan; Astra Zeneca, Cambridge, UK) after ensuring basic hemodynamic monitoring (ECG, pulse oximetry, and noninvasive blood pressure). Also, a neuromuscular block was performed using atracurium (Atrabesylate; Egypharma, Nasr City, Egypt), while a nitrous oxide-oxygen–sevoflurane (Sevoflurane; Abbvie, Nasr City, USA) combination was used for maintenance. Intravenous ondansetron (Zofran; GSK-Glaxo Smith Kline, Brentford, Middlese, UK) was used as an antiemetic, whereas intravenous fentanyl 2 μg/kg (Fentanyl; Martindale Pharma, Building A2, Glory Park Avenue, Wooburn Green, High Wycombe, Buckinghamshire, HP10 0DF, UK) was commenced for intraoperative analgesia.

Blood pressure and heart rate were monitored throughout the operation. Any increase in blood pressure or heart rate over 20% compared with the baseline value was treated by increasing the sevoflurane concentration or fentanyl administration. Conversely, hypotension [decrease of >20% of the mean arterial blood pressure (MAP) from the baseline] was managed by Ringer lactate solution (250 ml) and ephedrine (intravenous increment 3 mg).

After completing the surgery, either modified radical mastectomy or conservative breast surgery (lumpectomy with axillary lymph node dissection), for the pectoral nerve blockade group (group B), an injection of 10 ml of bupivacaine 0.25% (Sunnypivacaine; Sunny Medical Group, Cairo, Egypt) between the pectoralis major and minor muscles (Pecs I block) was administered where pectoral nerves are located. In addition, another 20 ml of bupivacaine (0.25%) with the same concentration was injected between the pectoralis minor and serratus anterior muscles (Pecs II block), and it involves additional anesthesia to the intercostobrachial, long thoracic, and third-sixth intercostal nerves to provide more pain relief, especially in patients undergoing axillary dissection. This involves Pecs I in addition to a second injection between the pectoralis minor and serratus anterior muscles. In group A, a sham pectoral nerve block was performed by injecting the same volume of normal saline with the same technique.

Sham pectoral nerve block involved injecting saline in the patients in group A instead of local anesthesia by injecting the same volume using the same technique.

After the operation, all patients were transferred to the postanesthesia care unit and then to the internal ward unless there was a reason for ICU admission. Hemodynamic parameters were recorded at 2, 4, 6, 8, 10, 12, and 24 h. Postoperative pain was assessed using VAS [11]. The patient was instructed to place a mark on a line 10 cm in length indicating their level of pain, where 0 = no pain and 10 = severe pain. Pain severity was measured at 2, 4, 6, 8, 10, 12, and 24 h after the end of surgery.

If the patient reported VAS of more than 3, paracetamol 1 g over 20 min (Injectmol; Alexandria, Amriya, Egypt) was commenced. If the pain persisted after 20 min, nalbuphine (Naluphine; Amoun Pharmaceutical Co., Egypt) was administered in bolus doses El Obour city – Cairo (4 mg/bolus). Furthermore, intravenous ondansetron was used to manage nausea and vomiting.

Postoperative patient satisfaction was classified as poor, fair-good, or excellent. Postoperative (VAS) was our primary outcome, whereas intraoperative and postoperative opioid consumption, nausea, and vomiting were the secondary outcomes.

Statistical analysis

Data analysis: IBM's SPSS statistics for Mac, version 26.0 (SPSS Inc., Chicago, Illinois, USA), was used for statistical analysis of the collected data. For the assessment of quantitative data, the Shapiro–Wilk test was used for normality testing. Normally distributed data were described as mean and SD, and compared using the Student t test. Non-normally distributed data were described as median and interquartile range, while the Mann–Whitney test was used to compare between two groups. Qualitative data were described as number and percent and then compared using either χ2 or Fisher exact tests. For all of the mentioned tests, P vaule less than 0.05 was considered statistically significant.


  Results Top


The mean age of the included patients was 46.48 and 47.24 years in groups A and B, respectively. The mean BMI value was 28.77 and 28.47 kg/m2 in groups A and B, respectively. No significant difference was noted between the two groups in both the demographic variables of age and BMI (P > 0.05). Moreover, there was no significant difference between the two study groups in the type of operation performed (P = 0.107). Conservative mastectomy (lumpectomy with axillary lymph node dissection) was the most commonly performed operation in both study groups (84 and 64% of patients in both groups, respectively), while the remaining patients underwent a modified radical mastectomy. No significant difference was noted between the two groups in the operative time [Table 1].
Table 1: Demographic characteristics, operative time, and type of operation in the study groups

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Although the basal heart rate did not show a significant difference between the two groups (P = 0.399), the pectoral block group had significantly lower heart rates during the operation and the first 4 h following surgery. Nevertheless, the heart rates after that time point were comparable between the two groups (P > 0.05) [Table 2].
Table 2: Basal and follow-up heart rates in the study groups

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In terms of the MAP, no significant difference was observed between the two in intraoperative or postoperative readings, apart from the intraoperative 15-min reading, which was significantly lower in the pectoral block group compared with the controls (106.96 vs. 97.88 mmHg in the control and study groups, respectively, P = 0.048) [Table 3].
Table 3: Basal and follow-up mean arterial blood pressures in the study groups

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In terms of the postoperative VAS, the pectoral nerve group had significantly lower values compared with the controls during the first 10 h after surgery (P < 0.005). After that, both groups showed comparable results (P > 0.05). Patient satisfaction was significantly better in the pectoral block group compared with the controls (P < 0.001). Most of the patients who underwent pectoral blockade (92%) reported excellent satisfaction, while none of the controls reported satisfaction. On the contrary, six patients reported poor satisfaction in the control group, 24%, versus no patients who underwent a pectoral block. The remaining patients in both groups reported good satisfaction [Table 4].
Table 4: Visual analog scale scores and patient satisfaction in the study groups

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As shown in [Table 5], the dose of intraoperative fentanyl 2 μg/kg was markedly reduced in the pectoral block group compared with the controls (128 vs. 172.22 μg, respectively, P < 0.001). Also, the first analgesic request was significantly delayed in the pectoral block group, while administration of paracetamol and nalbuphine doses also showed a significant decrease in the same group (P < 0.001). In addition, the incidence of postoperative nausea and vomiting (PONV) was significantly decreased with the pectoral block (P = 0.037) [Table 5].
Table 5: Intraperative and postoperative analgesic requirements and postoperative nausea and vomiting in the studied groups

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  Discussion Top


Postoperative pain, either acute or chronic, along with shoulder dysfunction are the most common complications of the breast [12]. Moreover, it has been documented that uncontrolled acute perioperative pain is an independent risk factor for postmastectomy pain syndrome [13]. Thus, proper management of postmastectomy pain is of crucial importance. Not only does it improve patient experience after surgery but it also decreases the incidence of chronic postoperative pain [14].

Acute postoperative pain is managed by opioid analgesics in most centers. However, opioid administration is associated with undesirable side effects such as respiratory depression, dizziness, nausea, vomiting, and constipation [15].

Recently, regional anesthesia has been introduced as an effective and safe modality for managing postoperative pain [16],[17]. Multiple regional techniques could be applied for breast surgery including paravertebral, epidural, and pectoral blocks. Nevertheless, the latter is not associated with an increased risk of sympathetic block, spinal cord injury, hypotension, or pneumothorax [18],[19].

The pectoral block is an interfascial plane block at which a local anesthetic is injected to provide regional anesthesia for both the chest wall and the axillary area [8],[9]. Since it was introduced in the field of pain medicine, multiple trials have reported its efficacy in reducing pain in patients undergoing breast surgeries [9],[12],[20],[21].

This study was carried out at Menoufia University Hospitals with the aim of assessing the efficacy and safety of supplementing general anesthesia with a pectoral nerve block in female patients undergoing a mastectomy. In terms of the general patient criteria, no significant difference was found between the two groups (P > 0.05). Another study focusing on the same subject also reported no significant difference between the two groups in the general characteristics of the patients (P > 0.05) [22]. Not only does this confirm our findings but it should also negate any bias that may have skewed the results in favor of one group rather than the other.

In the current study, there was no significant difference between the two study groups in the MAP during the operation. On the contrary, other authors reported that the changes in the mean blood pressure and heart rate were greater in the control group than in the pectoral block group [23]. This significant positive impact was more evident in the previous study as they applied the block before incision via ultrasound guidance, applying pre-emptive analgesia, which is considered to be more effective than a postincision blockade. Extensive studies are needed in the future to explore this concept further.

In our study, intraoperative fentanyl consumption was markedly reduced in the pectoral block group compared with the controls; the mean values were 128.0 and 172.22 μg in groups A and b, respectively (P < 0.001). In line with our findings, another study reported a significant decrease in intraoperative opioid consumption with the pectoral block when compared with the controls. The authors reported that the mean amount of fentanyl consumption was 331.8 and 530.2 μg in the pectoral and block groups, respectively (P < 0.001) [12].

In terms of the postoperative VAS in the current study, the pectoral block group showed significantly lower values compared with the controls during the first 10 h after surgery (P < 0.005). Similarly, another study reported that the mean VAS value was significantly lower in the pectoral block group than in the controls at 0 h (3.0 vs. 4.9, P < 0.001) and 0.5 h (3.6 vs. 5.1, P < 0.001) after the procedure [23]. Also, in another study, significantly more patients had mild pain and fewer patients had moderate pain in the block group compared with the controls, both at rest and on movement, at all measured time points [24].

Furthermore, in the study carried out by Mane et al. [25], the pectoral block group showed significantly lower pain scores at 6 h (P < 0.001) and 12 h (P < 0.001) compared with the controls. However, this significance disappeared at 24 h (P = 0.183). Another study also confirmed these findings [26].

In our study, patients who underwent a pectoral block showed a significant delay in the first analgesic request (P < 0.001), with mean values of 10 and 0.68 h in the block and control groups, respectively. Another study also reported that the application of a pectoral nerve block led to a significant delay in the first request for postoperative analgesia in breast surgeries (P = 0.008). The mean values were 170 and 130 min in the block and control groups, respectively [20]. In addition, Thomas et al.[24] confirmed the same findings as the time for the first analgesic request was 27.17 min for the controls versus 353.93 min for the block group (P = 0.002).

In the current study, there was a significant decrease in postoperative nalbuphine and paracetamol consumption in the pectoral block group (P < 0.001). The mean values of nalbuphine doses administered were 11.8 and 22 mg, while the mean values of paracetamol doses administered were 670 and 1340 mg in the block and control groups, respectively.

In line with our findings, Kim et al.[23] reported that fentanyl consumption during the first 24 h after surgery was significantly lower in the pectoral block group than in the control group (43.8 ± 28.5 vs. 77.0 ± 41.9 μg, P < 0.001). Another study also confirmed the previous findings as the total fentanyl consumption showed a significant decrease in the block group compared with the controls (50.88 vs. 67.83 μg in both groups, respectively, P = 0.001) [22]. Similarly, in 2017, Versyck et al.[18] conducted a randomized-controlled trial in Belgium and reported a decrease in the total opioid use from postanesthesia care unit discharge until the second postoperative day in patients who received a pectoralis blocks compared with placebo with saline.

Other authors used morphine for postoperative pain relief in such cases. They noted that postoperative morphine consumption was significantly decreased with the pectoral block when compared with the controls (1.75 vs. 5.42 mg in both groups, respectively, P < 0.001) [12]. In addition to the avoidance of complications, reducing the use of opioids in oncological surgeries may improve oncological outcomes as opioids have been reported to have immune-modulatory effects in addition to their analgesic effects such as the promotion of cell migration and expression of the NET 1 gene [27].

Furthermore, another study reported that the paracetamol dose administered was significantly decreased in the pectoral block group compared with the controls (P = 0.002), with mean values of 2.71 and 3.53 g in groups A and B, respectively [24]. This is also in agreement with our findings for paracetamol doses.

The incidence of nausea and vomiting was markedly decreased in the pectoral block group compared with the controls (20 vs. 48%, respectively, P = 0.037) in our study. This may most probably be due to a decrease in opioid requirement with regional techniques. Bashandy and Abbas[20] also reported that a pectoral nerve block was associated with lower PONV scores (0.15 ± 0.366 vs. 1.65 ± 0.875, with P < 0.001). Similarly, Abdallah et al. reported that there was a significant decrease in the incidence of PONV in the pectoral block group versus controls (32 vs. 88.7%, respectively, P < 0.001) [28]. Conversely, some other studies showed no significant effect of the pectoral block on the reduction of PONV compared with the controls [26],[29]. This heterogeneity could be attributed to the fact that PONV is a multifactorial problem. Multiple factors could be linked to this problem including perioperative opioid use, duration of anesthesia, and patient sex [26].

In the current study, the pectoral block group showed significantly better patient satisfaction. This is a rational consequence of better pain relief and decreased side effects in that group. Pérez et al.[30] also reported that patients undergoing major and minor breast surgeries reported significant postoperative satisfaction after the application of pectoral blockade. Furthermore, another study reported that most patients in the block group reported grade III satisfaction, while most controls reported poor postoperative satisfaction (class I – 66.67%, P < 0.001) [26].

This study has several limitations. First of all, this was a single-center study that included a relatively small sample size. Also, the surgical injection technique should have been compared with a pre-incision ultrasound-guided block to determine which will offer better pain control and better intraoperative hemodynamic control.


  Conclusion Top


Based on our findings, it is evident that pectoral nerve block is a safe and effective technique that offers effective pain relief after breast surgery. It leads to decreased analgesic consumption and increased patient satisfaction. Its application in the enhanced recovery program after modified radical mastectomy and conservative breast surgery (lumpectomy with axillary lymph node dissection) should be encouraged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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