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


BMC Anesthesiol. 2020;20(290) 

In This Article


Protocol and Registration

We performed a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.[8] Randomized controlled trials that compared the effects of locoregional anesthesia to systemic analgesia alone in patients undergoing breast surgery were sought. Studies were evaluated using a pre-designed protocol. The protocol was not published, and the review was not registered with the International prospective register of systematic reviews (PROSPERO).

Eligibility Criteria

The population, intervention, comparison, and outcome (PICO) criteria were applied to the research question (see Table 1). Patients older than 18 years undergoing breast surgery were considered as the population (P); the intervention (I) was postoperative analgesia with locoregional anesthesia techniques; the comparison (C) concept was standard pain treatment provided in each study; pain intensity, opioid consumption, adverse events (AEs), and patient satisfaction were considered the outcomes (O) for this systematic review. We included randomized controlled trials (RCTs) published from 2010 to the present. No language restrictions were placed on study inclusion.

Literature Search

We identified the articles by searching electronic databases (Embase, MEDLINE, Google Scholar and Cochrane Central Trials Register). We included other relevant studies from the reference lists of systematic reviews and meta-analyses. These databases were initially searched from Mars 2020.

The search strategy was developed using medical subject headings and keywords relating to the central research question of this paper. Namely, the search terms included in the search strategy covered the following key domains: "breast augmentation", "breast reduction", "mastectomy", "mastopexy", "local anesthetic agent", "postoperative pain" and "randomized clinical trial".

We applied no language restrictions in searches.

The studies included in this review evaluated adult patients undergoing breast surgery and receiving any type of locoregional anesthesia to treat postoperative pain.

Primary Outcomes

Pain scores and opioid consumption in the first 48 h postoperatively were the primary outcomes of interest. Pain intensity was assessed via a Numeric Rating Scale (NRS) at 1, 6, 12, 24 and 48 h after surgery. Pain intensity data assessed by means other than a zero to 10 NRS were converted to this scale. The other primary outcome was the average per patient opioid consumption in the Post-Anesthesia Care Unit (PACU) and in the 48 h after surgery. Opioid consumption was converted to morphine sulfate equivalents.[9]

Secondary Outcomes

We extracted data on the following secondary outcomes:

  1. Adverse Events (AEs) were recorded. Evaluated safety outcomes included postoperative opioid related side-effects (postoperative nausea and vomiting, sedation/respiratory depression, pruritus, hypotension, urinary retention, or constipation), and complications related to the nerve block (pneumothorax, block failure, or local anesthetic systemic toxicity). Complications during wound healing were also analysed.

  2. Patient Satisfaction. All measures of patient satisfaction were reported as "satisfied" and "not satisfied".

Selection of Studies

Two independent reviewers (P.S. and L.G.G.) initially assessed the results from the literature search based on title and abstract. The full-text citations of potentially eligible articles were subsequently retrieved and reviewed again by the same two independent reviewers. In case of disagreement between the two reviewers on eligibility, a discussion was initiated. If consensus could not be reached after discussion, a third reviewer (M.C.P.) evaluated the study and made the final decision.

The methodological quality of the included studies was evaluated and rated using the COSMIN checklist, based on a 4-point rating scale.

Data Extraction and Management

A standardized data extraction form was used. Data collected included information relating to:

  • Age, weight, height and body mass index (BMI) of participants;

  • Number of participants enrolled and completing the study;

  • Type of operation;

  • Regional anesthesia technique (local anesthetic and dose);

  • Pain intensity for all-time points at which it was measured;

  • Opioid consumption;

  • Patient satisfaction;

  • Severity or incidence of adverse events.

Statistical Analyses

For continuous outcomes, we extracted the mean and standard deviation (SD). In situations where these are not reported, the median and interquartile range were used to approximate these values. Similarly, in situations where the mean and 95% CI are reported, statistical conversions were used to estimate the mean and SD.

For dichotomous outcomes (side effects, complications), data were converted to overall incidence numbers.

We designated a p value < 0.05 as a threshold of statistical significance for the primary and secondary outcomes. All tests were two-tailed.