Single-injection regional analgesia techniques for mastectomy surgery

Abstract

BACKGROUND Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.OBJECTIVES To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.DESIGN Systematic review with network meta-analysis (PROSPERO: CRD42021250651).DATA SOURCE PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).ELIGIBILITY CRITERIA All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.RESULTS Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pectoserratus plane block (mean difference -1.3, 95% CI, -1.6 to -1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).CONCLUSION All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.TRIAL REGISTRATION PROSPERO (CRD4202125065).

Pain treatment and prophylaxis on pain

“…For most ambulatory procedures and patients, the latter will usually be considered too time-consuming as well as not needed. Simple, traditional multimodal analgesia, including local anaesthesia wound infiltration, will be sufficient in most cases [38,39]. This is highly valid for the centro-axial blocks (i.e.…”

Regional anaesthesia techniques for mastectomies

“…For instance, IP þ PS has been shown to be superior to ESPB in many previous studies, including a recent Bayesian NMA. 3 Cassai et al 1 included studies of mastectomies with or without axillary node clearance. We emphasise that breast surgery is 'multidimensional' and we must select the regional techniques according to the nature of the surgery and the extent of the incision, with a detailed understanding of the sensory block required for the procedure and the sensory block provided by the regional techniques chosen.…”

“…We read with great interest the network meta-analysis (NMA) which evaluated the various regional anaesthesia techniques for breast surgery 1 . We congratulate De Cassai et al 1 for their different approach to applying a NMA for comparing nine regional techniques and wish to add a few more insights.…”

“…De Cassai et al 1 concluded that no single regional analgesic technique was better than others for mastectomies. However, it was only statistically significant, and we need to consider its clinical applications.…”

“…Last but not the least, we would like to highlight that one referenced study of this NMA (Ref. 65 of Cassai et al 1 ) is not included in PubMed, Scopus or the Cochrane database, which is a complete violation of the selection criteria adopted for this NMA. Moreover, that referenced study did not assess morphine consumption which is another serious flaw with the inclusion of that study for an article of a meta-analysis nature.…”