What Is the Role of Locoregional Anesthesia in Breast Surgery?

A Systematic Literature Review Focused on Pain Intensity, Opioid Consumption, Adverse Events, and Patient Satisfaction

Pasquale Sansone; Luca Gregorio Giaccari; Mario Faenza; Pasquale Di Costanzo; Sara Izzo; Caterina Aurilio; Francesco Coppolino; Maria Beatrice Passavanti; Vincenzo Pota; Maria Caterina Pace

Disclosures

BMC Anesthesiol. 2020;20(290) 

In This Article

Background

Rationale

Breast surgery in the United States is common. In 2020, an estimated 276,480 new cases of invasive breast cancer will be diagnosed among women and approximately 80% of patients will have surgery to remove their primary tumour.[1] In addition, an increasing number of women are turning to plastic surgeons for interventions of cosmetic: among these breast augmentation is the first procedure performed in the United States.[2]

Pain affects up to 50% of women undergoing breast surgery and can interfere with postoperative outcomes. Breast pain is one of the factors determining patient distress, long hospital stay, and an increase in post-surgical admissions to the hospital.[3]

Nociceptive/inflammatory pain is caused by tissue damage, whereas neuropathic pain is the consequence of a central and peripheral nerve damage,[4] especially the intercostal nerves from T2 to T6. Neuropathic pain typically begins immediately after breast surgery and can be persistent, sometimes even for months.[3]

The pain control is the main objective of anesthesia in breast surgery. The correct management of acute postoperative pain is essential to improve patient outcome and satisfaction.

Various anesthetic agents, devices, and strategies are currently available. For a long time, intravenous analgesia has been the main technique for postoperative pain relief. Over the years, the growing number of surgical procedures for breast cancer and cosmetic treatment has however stimulated the development of new anesthetic techniques with improved pain reduction and safety, and fewer complications.

The international guidelines recommended the use of a multimodal analgesia.[5,6] Regional anesthesia techniques are effective as a component of multimodal analgesia for management of postoperative pain associated with a number of surgical procedures. These techniques can be administered as a single shot or a continuous catheter, both prior to surgical incision or after surgery.[5,6] Local anesthetics infiltration also shows benefit for the surgical procedure. Wound infiltration can be performed either as a single injection of local anesthetic typically at the conclusion of surgery or as a continuous infusion of local anesthetic through a catheter at the incision site prior to skin closure.[5,6] Finally, the international guidelines suggest the use of intravenous (IV) lidocaine, especially in patients underwent open or laparoscopic abdominal surgical procedures.[5,6] Perioperative lidocaine infusion may be considered for patients undergoing mastectomy.[7]

Objectives

We undertook this systematic review to identify the potential clinical role of locoregional anesthesia for breast surgery. We aimed to establish the efficacy and the safety of locoregional anesthesia in the pain management after breast surgery. Postoperative pain severity and opioid consumption during the first 48 h were designated as co-primary outcomes. For secondary objectives, we aimed to examine the effects on the immediate quality of recovery, in relation to adverse effects and patient satisfaction.

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