|Year : 2018 | Volume
| Issue : 4 | Page : 254-262
Newer regional analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature
Rakesh Garg, Swati Bhan, Saurabh Vig
Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||11-Apr-2018|
Dr. Rakesh Garg
Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Room No. 139, Ist Floor, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Surgical resection of the primary tumour with axillary dissection is one of the main modalities of breast cancer treatment. Regional blocks have been considered as one of the modalities for effective perioperative pain control. With the advent of ultrasound, newer interventions such as fascial plane blocks have been reported for perioperative analgesia in breast surgeries. Our aim is to review the literature for fascial plane blocks for analgesia in breast surgeries. The research question for initiating the review was 'What are the reported newer regional anaesthesia techniques (fascial plane blocks) for female patients undergoing breast surgery and their analgesic efficacy?.' The participants, intervention, comparisons, outcomes and study design were followed. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. Of the 989 manuscripts, the present review included 28 manuscripts inclusive of all types of published manuscripts. 15 manuscripts directly related to the administration of fascial plane blocks for breast surgery across all type of study designs and cases were reviewed for the utility of fascial plane blocks in breast surgeries. Interfascial blocks score over regional anaesthetic techniques such as paravertebral block as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to haemodynamic instability and prolonged hospital stay. This review observed that no block effectively covers the whole of breast and axilla, thus a combination of blocks should be used depending on the site of incision and extent of surgical resection.
Keywords: Breast surgeries, fascial plane blocks, interfascial plane block, mastectomy, regional analgesia
|How to cite this article:|
Garg R, Bhan S, Vig S. Newer regional analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature. Indian J Anaesth 2018;62:254-62
|How to cite this URL:|
Garg R, Bhan S, Vig S. Newer regional analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature. Indian J Anaesth [serial online] 2018 [cited 2018 Apr 23];62:254-62. Available from: http://www.ijaweb.org/text.asp?2018/62/4/254/229801
| Introduction|| |
Breast cancer is one of the common malignancies among women, accounting for 25%–32% of all female cancers in India. Surgical resection of the primary tumour with axillary dissection is one of the main modalities of breast cancer treatment. The most common modality for anaesthesia is general anaesthesia with or without regional blocks. It has been reported that 40% of the females report moderate-to-severe pain in the immediate post-operative period after breast cancer surgery. Acute post-surgical pain leads to delayed discharge from post-operative recovery area, impairs pulmonary and immune functions, increases risk of ileus, thromboembolism, myocardial infarction and may lead to increased length of hospital stay. It is also an important factor leading to the development of chronic persistent post-operative pain in almost half of the patients.,, Post-operative pain, stress and use of morphine have been elucidated as factors responsible for increased risk of metastasis. Hence, an effective perioperative pain management of patients undergoing breast surgery is essential. Regional blocks have been considered as one of the modalities for effective perioperative pain control. They have an opioid-sparing effect, and allow early mobilisation and early discharge from hospital. With the advent of ultrasound, newer interventions such as fascial plane blocks have been reported for perioperative analgesia in breast surgeries [Table 1]. The objective of this review was to evaluate the newer options for regional interventions in patients undergoing breast surgery and to suggest further research and practices. Our aim in this paper is to analyse the literature reporting the use of fascial plane blocks and to asses their efficacy as alternate modes of analgesia in breast surgeries.
|Table 1: Fascial plane blocks for perioperative analgesia in breast surgeries|
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| Methods|| |
The research question for initiating the review was 'What are the newer regional techniques (fascial plane blocks) reported for female patients undergoing breast surgery and their analgesic efficacy?' The participants, intervention, comparisons, outcomes and study design (PICOS) format was followed for this review as per PRISMA statement. The components included were as follows.
Studies enrolling female adults undergoing breast surgery.
Interventions included the use of any interfascial plane blocks for perioperative analgesia in patients undergoing breast surgery.
It included both the regional techniques and other intravenous method of analgesia.
The outomes were pain scores and analgesic efficacy.
This review included prospective, retrospective, randomised, non-randomised, blinded, non-blinded or cohort studies. Due to the paucity of studies, we also included case reports and case studies.
The explorative search was done from PubMed, Cochrane Library, Google Scholar and Embase databases for all the related manuscripts till December 2017. The keywords used included 'analgesics', OR 'analgesia', OR 'nerve block', OR 'plexus block', OR 'plane block', OR 'regional anesthesia', OR 'anaesthesia', OR 'infiltration' AND 'mammoplasty', OR 'mastectomy', OR 'breast surgery', OR 'breast cancer surgery' and OR 'breast augmentation'. The assessed manuscripts were further checked for their bibliography for any missing manuscripts and further manual search for these articles was undertaken. The titles and abstracts were manually screened for assessing the suitability for inclusion into the review. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. Hence, we report the quasi-systematic review of fascial plane blocks for breast surgery.
| Results|| |
Of the 989 manuscripts, the present review included 28 manuscripts inclusive of all types of published manuscripts that fulfilled the 'PICOS' criteria as defined for our research question. Of these, only 15 manuscripts which were directly related to the administration of fascial plane blocks for breast surgery across all type of study designs and cases were reviewed for the utility of fascial plane blocks in breast surgeries. The rest of the articles were comments and editorials in general [Figure 1]. [Table 2] summarises the articles included, technique of fascial plane block used and the main outcome related to it.,,,,,,,,,,,,,,,,,,,,,
|Table 2: Published studies for use of fascial plane blocks for breast surgeries|
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| Discussion|| |
Various regional anaesthetic techniques such as local wound infiltration, thoracic epidural, thoracic paravertebral block (PVB), and more recently, ultrasound-guided fascial plane blocks have been used to provide analgesia in breast surgeries. These techniques not only manage acute post-operative pain but also help prevent chronic post-surgical pain and may prevent cancer recurrence.
PVB has long been considered the gold standard technique in patients undergoing breast cancer surgery. The potential complications of PVB include vascular puncture, pneumothorax, intrathecal or epidural spread and sympathetic block leading to haemodynamic instability. With the introduction of ultrasound in the operating room, regional anaesthesia practice has undergone a remarkable change. The conventional techniques are being replaced by newer and safer techniques. In breast surgeries, ultrasound-guided newer interfascial plane blocks have been described which are being used as effective alternatives to invasive procedures such as PVB.
The utility of these interfascial blocks in breast surgery is based on the nerve supply of breast. Neural innervations of the anterior chest wall and breast involve various nerves which need to be blocked effectively for optimal analgesia [Table 3]. Blockade of the T2–T9 dermatome would be acceptable for optimal pain management in modified radical mastectomy. Interfascial plane blocks described for analgesia of chest have been found to be covering these dermatomes and thus appear to be effective for perioperative analgesia following breast surgeries [Table 1].,,,,,, Since the description of these newer and safer interfascial plane blocks, various authors have studied their use in breast surgeries. At present, it is difficult to determine the superiority of one technique over the other in view of insufficient data. However, it appears that these techniques would be promising in future. Large well-conducted prospective randomised studies are required to confirm the utility of either of these interfascial plane blocks for breast surgeries.
Majority of the authors advocate giving a combination of blocks to cover analgesia over whole of the chest wall, axilla and shoulder.,,,,,,,,,, The majority of evidence in the application of interfascial plane blocks for breast surgeries exists in the form of case reports or case series. In the reported case reports, these blocks were used with general anaesthesia and were useful in reducing intra- and post-operative analgesic requirements.,, Combination of blocks was used as per the area of the surgery or anaesthesiologists preference and no standard guidelines exist on blocks to be used for specific surgeries. In general, pectoralis nerve block 1 (PECS1) and serratus anterior plane (SAP) block when used alone lead to sparing of axilla, medial and posterior part of chest, and hence may be combined with PECS2 to cover the axilla; and pectoro-intercostal fascial block (PIFB) to cover medial part of the breast.,,, Erector spinae block theoretically can provide analgesia over the posterior part of the chest wall, although limited evidence exists in literature for its use in breast surgeries.
As mentioned, a limited number of randomised control trials has been published till date comparing these interfascial blocks with established techniques of analgesia for breast surgeries such as PVB, or comparing these interfascial blocks among themselves for a specific type of breast surgery.,,,,,, Among the studies reported, PECS has been compared with thoracic paravertebral in two studies; the results were conflicting, with one showing PECS2 block superior to thoracic paravertebral for post-operative analgesia after breast resection, and the other showing thoracic paravertebral to be superior., These studies were not comparable as they had heterogeneous patient criteria, differing types of surgery and variable techniques and drugs for PECS block. A single study has evaluated the addition of adjuvant -ketamine in local anaesthetic in PECS block. Positive results were seen with addition of ketamine in the form of prolonged duration of analgesia. No comment on was made on the ideal dose of ketamine to be added as adjuvant in PECS block.
In the evidence for SAP block, one case series has focused on the use of SAP block with additive dexamethasone for patients having chronic post-mastectomy pain and has shown positive results. A single published randomised controlled trial comparing serratus plane block with paravertebral showed paravertebral to be superior to SAP block for acute post-operative analgesia in patients undergoing modified radical, mastectomy. None of the randomised control trials reported above have followed up the patients for the development of chronic post-operative pain and the benefit of the block given at the time of surgery as a preventive technique to reduce the incidence of chronic post-operative pain has not been studied.
Use of these blocks may have several limitations such as failure of block in altered anatomy  or hindrance to surgical electrocautery. In cases where the sonoanatomy of the chest wall may be altered, for example, post-mastectomy contractures of the chest wall, ultrasound-guided interfascial block-like PECS may not be feasible. Alternate techniques of analgesia such as supraclavicular brachial plexus block may be used to block the median and lateral pectoral nerves. In addition, intercoastal nerve block may be used to effectively manage post-mastectomy pain. Complications such as reduced efficacy of electrocautery due to tissue oedema caused by the collection of local anaesthetic between the muscle layers have been observed. These may be overcome using harmonic scalpel or bipolar cautery. In addition, concerns related to interference of surgical dissection due to deposition of drugs in the fascial plane needs to be studied further. Such complications should be kept in mind and reported in detail in future studies to further fine-tune techniques of block and related changes in surgical technique.
One of the major limitations of this review was difficulty to access evidence in a synthesizable form because of limited literature and heterogeneity across studies to perform meaningful quantitative comparisons. For the same reason, quality assessment for the included manuscript was not feasible. A number of lacunae exist in our knowledge regarding the efficacy of the fascial blocks for breast surgeries. Further, randomised control trials are needed in homogenous group of breast procedures to evaluate each of these techniques against established techniques of analgesia such as PVB. In addition, well-structured randomised studies are needed to compare these blocks against each other to establish a given technique with maximum efficacy. Attempts should be made to follow-up these patients in long-term to study the effect of these blocks as preventive techniques to prevent the development of chronic pain.
| Conclusion|| |
Description of the interfascial blocks to cover analgesia for breast surgeries opens up an exciting avenue for the anaesthesiologist. The practice of taking up breast surgeries as day care procedures favour administrating analgesic techniques with minimal residual or adverse effects. Interfascial blocks score over regional anaesthetic techniques such as PVB as they have no risk of sympathetic blockade, intrathecal or epidural spread which may lead to haemodynamic instability and prolonged hospital stay. This review observed that no block effectively covers whole of breast and axilla, thus a combination of blocks may be used depending on the site of incision and extent of surgical resection.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Population Based Cancer Registry. National Cancer Registry Programme (NCRP), Indian Council of Medical Research (ICMR). Available from: http://www.ncrpindia.org/
. [Last accessed on 2018 Jan 10].
Poleshuck EL, Katz J, Andrus CH, Hogan LA, Jung BF, Kulick DI, et al.
Risk factors for chronic pain following breast cancer surgery: A prospective study. J Pain 2006;7:626-34.
Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North America 2005;23:21-36.
Shapiro FE. Anesthesia for outpatient cosmetic surgery. Curr Opin Anaesthesiol 2008;21:704-10.
Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H, et al.
Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA 2009;302:1985-92.
Garg R. Regional anaesthesia in breast cancer: Benefits beyond pain. Indian J Anaesth 2017;61:369-72.
] [Full text]
Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol 2011;27:5-11.
] [Full text]
Blanco R. The 'pecs block': A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66:847-8.
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:470-5.
Nair AS. Cutaneous innervations encountered during mastectomy: A perplexing circuitry. Indian J Anaesth 2017;61:1026-7.
] [Full text]
Tewari S, Dhiraaj S, Sachan V, Bhargava T, Verma A. Ultrasound as a point-of-care tool for early detection of potential complications like pneumothorax associated with the pectoralis block. Indian J Anaesth 2017;61:852-3.
] [Full text]
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.
Hong B, Yoon SH, Youn AM, Kim BJ, Song S, Yoon Y, et al.
Thoracic interfascial nerve block for breast surgery in a pregnant woman: A case report. Korean J Anesthesiol 2017;70:209-12.
Khemka R, Chakraborty A, Ahmed R, Datta T, Agarwal S. Ultrasound-guided serratus anterior plane block in breast reconstruction surgery. A A Case Rep 2016;6:280-2.
Zocca JA, Chen GH, Puttanniah VG, Hung JC, Gulati A. Ultrasound-guided serratus plane block for treatment of postmastectomy pain syndromes in breast cancer patients: A case series. Pain Pract 2017;17:141-6.
Othman AH, El-Rahman AM, El Sherif F. Efficacy and safety of ketamine added to local anesthetic in modified pectoral block for management of postoperative pain in patients undergoing modified radical mastectomy. Pain Physician 2016;19:485-94.
Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: A randomized controlled trial. Br J Anaesth 2016;117:382-6.
Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: A randomized clinical trial. Reg Anesth Pain Med 2015;40:68-74.
Hards M, Harada A, Neville I, Harwell S, Babar M, Ravalia A, et al.
The effect of serratus plane block performed under direct vision on postoperative pain in breast surgery. J Clin Anesth 2016;34:427-31.
Kim H, Shim J, Kim I. Surgical excision of the breast giant fibroadenoma under regional anesthesia by Pecs II and internal intercostal plane block: A case report and brief technical description: A case report. Korean J Anesthesiol 2017;70:77-80.
Syal K, Chandel A. Comparison of the post-operative analgesic effect of paravertebral block, pectoral nerve block and local infiltration in patients undergoing modified radical mastectomy: A randomised double-blind trial. Indian J Anaesth 2017;61:643-8.
] [Full text]
Ohgoshi Y, Yokozuka M, Terajima K. Serratus-intercostal plane block for breast surgery. Masui 2015;64:610-4.
Chakraborty A, Khemka R, Datta T, Mitra S. COMBIPECS, the single-injection technique of pectoral nerve blocks 1 and 2: A case series. J Clin Anesth 2016;35:365-8.
Moon EJ, Kim SB, Chung JY, Song JY, Yi JW. Pectoral nerve block (Pecs block) with sedation for breast conserving surgery without general anesthesia. Ann Surg Treat Res 2017;93:166-9.
Veiga M, Costa D, Brazão I. Erector spinae plane block for radical mastectomy: A new indication? Rev Esp Anestesiol Reanim 2018;65:112-5.
Ohgoshi Y, Ikeda T, Kurahashi K. Continuous erector spinae plane block provides effective perioperative analgesia for breast reconstruction using tissue expanders: A report of two cases. J Clin Anesth 2018;44:1-2.
Gupta K, Srikanth K, Girdhar KK, Chan V. Analgesic efficacy of ultrasound-guided paravertebral block versus serratus plane block for modified radical mastectomy: A randomised, controlled trial. Indian J Anaesth 2017;61:381-6.
] [Full text]
Osaka Y, Morita Y. Supraclavicular brachial plexus block is an alternative to pectoral nerve block 1 for contracture reconstruction post mastectomy. J Clin Anesth 2018;46:12.
Bakshi SG, Karan N, Parmar V. Pectoralis block for breast surgery: A surgical concern? Indian J Anaesth 2017;61:851-2.
] [Full text]
Syed A, Devkaran A, Mehta S, Michail M, Bradpiece H. Post operative analgesia for breast surgery: Intercostal nerve blocks versus subcutaneous infiltration. Cancer Res 2009;69 24 Suppl: 5052.
[Table 1], [Table 2], [Table 3]