Korean J Pain.  2021 Jan;34(1):106-113. 10.3344/kjp.2021.34.1.106.

The efficacy of ultrasound-guided erector spinae plane block after mastectomy and immediate breast reconstruction with a tissue expander: a randomized clinical trial

• Park S
• Park J
• Choi JW
• Bang YJ
• Oh EJ
• Park J
• Hong KY
• Sim WS

• KMID: 2510317
• DOI: http://doi.org/10.3344/kjp.2021.34.1.106

Abstract

Background
We aimed to investigate the analgesic efficacy of an erector spinae plane block (ESPB) in immediate breast reconstruction (IBR) with a tissue expander.
Methods
Adult women undergoing IBR with a tissue expander after mastectomy were randomly assigned to either intravenous patient-controlled analgesia (IV-PCA) alone (group P) or IV-PCA plus ESPB (group E). The primary outcome was the total amount of opioid consumption during 24 hours postoperatively between the two groups. Secondary outcomes were patient satisfaction, pain score at rest and on shoulder movement using numerical rating scale, incidences of postoperative nausea and vomiting (PONV), and a short form of the brief pain inventory (BPI-SF) at 3 and 6 months after surgery between the groups.
Results
Fifty eight patients completed the study. At 24 hours postoperatively, total opioid consumption was significantly less in group E than in group P (285.0 ± 92.0, 95% confidence interval [CI]: 250.1 to 320.0 vs. 223.2 ± 83.4, 95% CI: 191.5 to 254.9, P = 0.005). Intraoperative and cumulative PCA fentanyl consumption at 3, 6, 9, and 24 hours were also less in group E than in group P (P = 0.004, P = 0.048, P = 0.020, P = 0.036, and P < 0.001, respectively). Patient satisfaction was higher in group E (6.9 ± 1.8 vs. 7.8 ± 1.4, P = 0.042). The incidences of PONV was similar.
Conclusions
The ESPB decreased postoperative opioid consumption and increased patient satisfaction without significant complications after IBR with a tissue expander after mastectomy.

Keyword

Analgesia; Breast Implants; Breast Neoplasms; Mastectomy; Nerve Block; Pain; Postoperative; Patient Satisfaction; Reconstructive Surgical Procedures; Tissue Expansion Devices; Ultrasonography; Interventional

Figure

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  Fig. 1 Consolidated standards of reporting trials flow diagram. IV-PCA: intravenous patient-controlled analgesia, ESPB: erector spinae plane block.

Reference

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. 2018; Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 68:394–424. DOI: 10.3322/caac.21492. PMID: 30207593.

2. Gassman AA, Yoon AP, Maxhimer JB, Sanchez I, Sethi H, Cheng KW, et al. 2015; Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions. Plast Reconstr Surg. 135:356–67. DOI: 10.1097/PRS.0000000000000989. PMID: 25626783.

3. Caffo O, Amichetti M, Ferro A, Lucenti A, Valduga F, Galligioni E. 2003; Pain and quality of life after surgery for breast cancer. Breast Cancer Res Treat. 80:39–48. DOI: 10.1023/A:1024435101619. PMID: 12889597.

4. Andersen KG, Duriaud HM, Jensen HE, Kroman N, Kehlet H. 2015; Predictive factors for the development of persistent pain after breast cancer surgery. Pain. 156:2413–22. DOI: 10.1097/j.pain.0000000000000298. PMID: 26176893.

5. Kehlet H, Jensen TS, Woolf CJ. 2006; Persistent postsurgical pain: risk factors and prevention. Lancet. 367:1618–25. DOI: 10.1016/S0140-6736(06)68700-X. PMID: 16698416.

6. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. 2016; The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 41:621–7. DOI: 10.1097/AAP.0000000000000451. PMID: 27501016.

7. Gürkan Y, Aksu C, Kuş A, Yörükoğlu UH. 2020; Erector spinae plane block and thoracic paravertebral block for breast surgery compared to IV-morphine: a randomized controlled trial. J Clin Anesth. 59:84–8. DOI: 10.1016/j.jclinane.2019.06.036. PMID: 31280100.

8. Aksu C, Kuş A, Yörükoğlu HU, Tor Kılıç C, Gürkan Y. 2019; Analgesic effect of the bi-level injection erector spinae plane block after breast surgery: a randomized controlled trial. Agri. 31:132–7. DOI: 10.14744/agri.2019.61687. PMID: 31736025.

9. Taketa Y, Irisawa Y, Fujitani T. 2019; Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery: a randomized controlled non-inferiority clinical trial. Reg Anesth Pain Med. doi: 10.1136/rapm-2019-100827. DOI: 10.1136/rapm-2019-100827. PMID: 31704789.

10. Oksuz G, Bilgen F, Arslan M, Duman Y, Urfalıoglu A, Bilal B. 2019; Ultrasound-guided bilateral erector spinae block versus tumescent anesthesia for postoperative analgesia in patients undergoing reduction mammoplasty: a randomized controlled study. Aesthetic Plast Surg. 43:291–6. DOI: 10.1007/s00266-018-1286-8. PMID: 30535555.

11. Hong B, Bang S, Chung W, Yoo S, Chung J, Kim S. 2019; Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study. Korean J Pain. 32:206–14. DOI: 10.3344/kjp.2019.32.3.206. PMID: 31257829. PMCID: PMC6615445.

12. Kang R, Chin KJ, Gwak MS, Kim GS, Choi SJ, Kim JM, et al. 2019; Bilateral single-injection erector spinae plane block versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: a randomized non-inferiority trial. Reg Anesth Pain Med. doi: 10.1136/rapm-2019-100902. DOI: 10.1136/rapm-2019-100902. PMID: 31649028.

13. Altıparmak B, Korkmaz Toker M, Uysal Aİ, Turan M, Gümüş Demirbilek S. 2019; Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: a prospective, randomized, controlled trial. J Clin Anesth. 54:61–5. DOI: 10.1016/j.jclinane.2018.10.040. PMID: 30396100.

14. Zhang J, He Y, Wang S, Chen Z, Zhang Y, Gao Y, et al. 2020; The erector spinae plane block causes only cutaneous sensory loss on ipsilateral posterior thorax: a prospective observational volunteer study. BMC Anesthesiol. 20:88. DOI: 10.1186/s12871-020-01002-0. PMID: 32312233. PMCID: PMC7169010.

15. Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. 2004; Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain. 20:309–18. DOI: 10.1097/00002508-200409000-00005. PMID: 15322437.

16. Wang K, Zhang X, Zhang T, Yue H, Sun S, Zhao H, et al. 2018; The efficacy of ultrasound-guided type II pectoral nerve blocks in perioperative pain management for immediate reconstruction after modified radical mastectomy: a prospective, randomized study. Clin J Pain. 34:231–6. DOI: 10.1097/AJP.0000000000000529. PMID: 28654558.

17. Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, et al. 2019; The erector spinae plane block: a narrative review. Korean J Anesthesiol. 72:209–20. DOI: 10.4097/kja.d.19.00012. PMID: 30886130. PMCID: PMC6547235.

18. Adhikary SD, Bernard S, Lopez H, Chin KJ. 2018; Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Reg Anesth Pain Med. 43:756–62. DOI: 10.1097/AAP.0000000000000798. PMID: 29794943.

19. Yang HM, Choi YJ, Kwon HJ, O J, Cho TH, Kim SH. 2018; Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: a cadaveric study. Anaesthesia. 73:1244–50. DOI: 10.1111/anae.14408. PMID: 30113699.

20. Ivanusic J, Konishi Y, Barrington MJ. 2018; A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 43:567–71. DOI: 10.1097/AAP.0000000000000789. PMID: 29746445.

21. Dautzenberg KHW, Zegers MJ, Bleeker CP, Tan ECTH, Vissers KCP, van Geffen GJ, et al. 2019; unpredictable injectate spread of the erector spinae plane block in human cadavers. Anesth Analg. 129:e163–6. DOI: 10.1213/ANE.0000000000004187. PMID: 31107261.

22. Choi YJ, Kwon HJ, O J, Cho TH, Won JY, Yang HM, et al. 2019; Influence of injectate volume on paravertebral spread in erector spinae plane block: an endoscopic and anatomical evaluation. PLoS One. 14:e0224487. DOI: 10.1371/journal.pone.0224487. PMID: 31658293. PMCID: PMC6816541.

23. Costache I, de Neumann L, Ramnanan CJ, Goodwin SL, Pawa A, Abdallah FW, et al. 2017; The mid-point transverse process to pleura (MTP) block: a new end-point for thoracic paravertebral block. Anaesthesia. 72:1230–6. DOI: 10.1111/anae.14004. PMID: 28762464.

24. Murouchi T, Yamakage M. 2016; Retrolaminar block: analgesic efficacy and safety evaluation. J Anesth. 30:1003–7. DOI: 10.1007/s00540-016-2230-1. PMID: 27518726.

25. Roué C, Wallaert M, Kacha M, Havet E. 2016; Intercostal/paraspinal nerve block for thoracic surgery. Anaesthesia. 71:112–3. DOI: 10.1111/anae.13358. PMID: 26684531.

26. Woodworth GE, Ivie RMJ, Nelson SM, Walker CM, Maniker RB. 2017; Perioperative breast analgesia: a qualitative review of anatomy and regional techniques. Reg Anesth Pain Med. 42:609–31. DOI: 10.1097/AAP.0000000000000641. PMID: 28820803.

27. Bang S. 2019; Erector spinae plane block: an innovation or a delusion? Korean J Anesthesiol. 72:1–3. DOI: 10.4097/kja.d.18.00359. PMID: 30732436. PMCID: PMC6369339.

28. Chiu C, Aleshi P, Esserman LJ, Inglis-Arkell C, Yap E, Whitlock EL, et al. 2018; Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy. BMC Anesthesiol. 18:41. DOI: 10.1186/s12871-018-0505-9. PMID: 29661153. PMCID: PMC5902852.

29. Kumar K, Kirksey MA, Duong S, Wu CL. 2017; A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg. 125:1749–60. DOI: 10.1213/ANE.0000000000002497. PMID: 29049119.

30. Peker K, Akçaboy ZN, Aydın G, Gençay I, Şahin AT, Koçak YF, et al. 2020; The effect of erector spinae plane block on laparoscopic cholecystectomy anesthesia: analysis of opioid consumption, sevoflurane consumption, and cost. J Laparoendosc Adv Surg Tech A. 30:725–9. DOI: 10.1089/lap.2019.0809. PMID: 32023174.

31. Chen YA, Rivera-Serrano CM, Chen C, Chen YR. 2016; Pre-surgical regional blocks in orthognathic surgery: prospective study evaluating their influence on the intraoperative use of anaesthetics and blood pressure control. Int J Oral Maxillofac Surg. 45:783–6. DOI: 10.1016/j.ijom.2015.09.014. PMID: 26811189.

32. Erturk E, Aydogdu Kaya F, Kutanis D, Besir A, Akdogan A, Geze S, et al. 2014; The effectiveness of preemptive thoracic epidural analgesia in thoracic surgery. Biomed Res Int. 2014:673682. DOI: 10.1155/2014/673682. PMID: 24745020. PMCID: PMC3972946.

33. Lee J, Kim S. 2019; The effects of ultrasound-guided serratus plane block, in combination with general anesthesia, on intraoperative opioid consumption, emergence time, and hemodynamic stability during video-assisted thoracoscopic lobectomy: a randomized prospective study. Medicine (Baltimore). 98:e15385. DOI: 10.1097/MD.0000000000015385. PMID: 31045789. PMCID: PMC6504301.

34. Yao Y, Li J, Hu H, Xu T, Chen Y. 2019; Ultrasound-guided serratus plane block enhances pain relief and quality of recovery after breast cancer surgery: a randomised controlled trial. Eur J Anaesthesiol. 36:436–41. DOI: 10.1097/EJA.0000000000001004. PMID: 31021882.

35. De Cassai A, Bonanno C, Sandei L, Finozzi F, Carron M, Marchet A. 2019; PECS II block is associated with lower incidence of chronic pain after breast surgery. Korean J Pain. 32:286–91. DOI: 10.3344/kjp.2019.32.4.286. PMID: 31569921. PMCID: PMC6813900.

36. Kim DH, Kim S, Kim CS, Lee S, Lee IG, Kim HJ, et al. 2018; Efficacy of pectoral nerve block type II for breast-conserving surgery and sentinel lymph node biopsy: a prospective randomized controlled study. Pain Res Manag. 2018:4315931. DOI: 10.1155/2018/4315931. PMID: 29861803. PMCID: PMC5976903.

37. Wang HJ, Liu Y, Ge WW, Bian LD, Pu LF, Jiang Y, et al. 2019; Comparison of ultrasound-guided serratus anterior plane block and erector spinae plane blockperioperatively in radical mastectomy. Zhonghua Yi Xue Za Zhi. 99:1809–13. Chinese.

38. Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. 2019; The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 53:29–34. DOI: 10.1016/j.jclinane.2018.09.036. PMID: 30292068.

39. Cao X, White PF, Ma H. 2017; An update on the management of postoperative nausea and vomiting. J Anesth. 31:617–26. DOI: 10.1007/s00540-017-2363-x. PMID: 28455599.

40. Shin S, Min KT, Shin YS, Joo HM, Yoo YC. 2014; Finding the 'ideal' regimen for fentanyl-based intravenous patient-controlled analgesia: how to give and what to mix? Yonsei Med J. 55:800–6. DOI: 10.3349/ymj.2014.55.3.800. PMID: 24719151. PMCID: PMC3990071.