ESRA19-0345 An evidence based departmental guideline for provision of regional anaesthesia in breast surgery

Background and aims Regional anaesthesia (RA) in breast surgery (BS) reduces post-operative1 2 3 and chronic pain.4 However, the possibility of reduced risk of malignant recurrence5 6 massively furthers its role in oncoplastic BS and the importance of the regional anaesthetist. The neuroendocrine response RA attenuates has multiple pro-malignant effects including depression of cell-mediated immunity, reducing tumour related anti-angiogenic factors and increasing proangiogenic factors.7 Additionally, opioids inhibit cellular and humoral immune function, increase angiogenesis and promote breast tumour growth in rodents. A large randomised-control trial assessing if the aforementioned effects of RA translate into reduced long-term recurrence7 is due to publish its findings imminently. Against this background we devised a guideline to increase and standardise the use of RA in oncological BS. Methods Google Scholar was used for a literature search. All local surgeons and anaesthetists undertaking BS were asked their opinions on RA in BS and their preferred modality thereof. The guideline is thus both evidence based and agreeable to relevant parties. Results Guideline summary is as follows. In all malignant BS, a block should be performed. The block should precede surgery. On account of its simplicity,8 superior efficacy,9 10 low complication rate and local favour, PECSII should be the block of choice with an additional PECSI subject to surgeon’s agreement. For axillary dissection, serratus anterior block can be offered subject to surgeon’s agreement. Paravertebral and intrapleural blocks are valid alternatives if PECSI and II are not possible. Conclusions Pain reduction alone justifies promotion and standardisation of RA in BS but if oncological benefit is proven, widespread deployment is essential. References Beverly A, Courtenay-Evans N, Rudiger J. Analgesia for Breast Surgery Regional vs. LA infiltration. Poster Presentation ESRA Annual Conference 2017. Moller JF, Nikolajsen L, Rodt SA, et al. Thoracic paravertebral block for breast cancer surgery: a randomized double-blind study. Anesth Anaig. 2007; 105: 1848–1851. Boughey JC, Goravanchi, F Parris, RN, et al. Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery. Am J Surg. 2009; 198: 720–725. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: A Cochrane systematic review and meta-analysis. Br J Anaesth. 2013; 111: 711–20. Heaney A, Buggy D. Can anaesthetic and analgesic techniques affect cancer recurrence or metastasis? Brit J Anaesth. 2012; 109: 117- i28. Garg R. Regional anaesthesia in breast cancer: Benefits beyond pain. Indian Anaesth. 2017; 61: 369–72. ClinicalTrials.gov [Internet]. Sessler D: The Cleveland Clinic (US). 2007 Jan 4 Identifier NCT00418457, Regional Anaesthesia and Breast Cancer Recurrence; 2007 Jan 4 [cited 2019 Feb 22]. Available from https://clinicaltrials ct2/show/study/NCT00418457 Blanco R. The “pecs block”: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011; 66: 847–848. Kulhari S, Bharti N, Bala I et al. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy a randomized controlled trial Brit JAnaesth. 2016; 117(3): 382–386. Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery. Egypt J Anaesth 2013; 30: 129–135.