Ultrasound-guided Erector Spinae Plane Block Versus Paravertebral Block in Breast Cancer Patients Undergoing Mastectomy With Immediate Reconstruction - a Non-inferiority Trial

Study Overview
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Brief Summary
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The objective of this study is to assess the non-inferiority of analgesic efficacy of ESP vs PVB for patients undergoing unilateral mastectomy followed by immediate reconstruction.

Detailed Description
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n breast cancer treatment, surgery plays a central role in combination with chemotherapy, radiation and immunotherapy. Surgery may vary from conservative breast sparing interventions to large radical mastectomies with axillary lymph node dissection that require reconstructive (prosthetic) surgery. In many instances, reconstruction is not performed immediately, but immediate reconstruction is possible and offers many advantages to patients. The Antoni van Leeuwenhoek hospital performs a large proportion (77%) of mastectomies with immediate reconstruction in the Netherlands. The combination of mastectomy with immediate reconstruction in one operation offers an extra challenge with regards to pain control. Post-operative pain is often treated with opioids, which has systemic side effects (nausea and vomiting). Opioids also inhibit cell-mediated immunity, which is a principal defense against cancer. Regional anesthetic techniques are often performed to reduce opioid consumption and enhance postoperative recovery. The current standard for regional anesthesia for breast surgery is the paravertebral block (PVB). This technique has the potential for severe complications such as epidural hematoma, hemo- or pneumothorax. The erector spinae plane block (ESP) was first described in 2016 as a novel regional anesthetic technique for acute and chronic thoracic pain. The site of injection is distant from the pleura, major blood vessels, and spinal cord; hence, the ESP block has relatively few contraindications and has therefore been suggested as an alternative to PVB when contra-indications, such as a bleeding diathesis, are present.Multiple studies have shown a decrease in opioid consumption in patients undergoing mastectomy, when ESP was compared to placebo. ESP has also been shown to be non-inferior to PVB for pain relief in patients undergoing thoracotomy. To date, only two studies have compared ESP to PVB for breast surgery, with conflicting results. In this study, we would like to investigate whether ESP can be considered non-inferior to PVB with regards to pain relief and use of opioids.

Official Title
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Ultrasound-guided Erector Spinae Plane Block Versus Paravertebral Block in Breast Cancer Patients Undergoing Mastectomy With Immediate Reconstruction - a Non-inferiority Trial. A Single-centre Randomized Controlled Non-inferiority Trial With a Parallel Group Design

Conditions
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Breast Cancer Patients Undergoing Mastectomy With Immediate Reconstruction

Intervention / Treatment
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* Drug: Morphine
* Other: Ultrasound-guided erector spinae plane block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult patients (18 years of age or older) ASA I-III Patients scheduled for elective unilateral mastectomy followed by direct reconstruction Ability to give written and oral informed consent Exclusion Criteria: Patient refusal Non-elective surgery Any contraindication to paravertebral block (including bleeding diathesis, coagulopathy, severe pulmonary disease ) Allergy to amide-linked local anesthetics Cardiac conductivity disorders (e:g: 2nd and 3rd AV-block) Severe spinal malformations or history of extensive spine surgery - A history of spinal cord injury Known psychiatric disorder Chronic pain patients or patients already using opioids pre-operatively Infection of the skin at the site of needle puncture area - Inability to give oral and written informed consent

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: paravertebral block<br> | Drug: Morphine<br>* Opiates<br>|
| Experimental: Ultrasound-guided erector spinae plane block<br> | Other: Ultrasound-guided erector spinae plane block<br>* PVB<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mean difference of highest numerical rating score (NRS - a linear 11 point scale for self-reported pain) during admission in the recovery room |  | 1 day | 
| Difference in the ratio of the means of cumulative opioid dose (administered during admission in the recovery room) |  | 1 day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Success rate as defined by satisfactory spread of local anaesthetic agents on ultrasound |  | 1 month | 
| Ease of procedure (self-reported by anaesthetist on scale of 1-5) |  | 1 month | 
| Total opioid dose administered on day 0 and on day 1 (iv, subcutaneous or oral - converted to morphine equivalent dose (MEQ) |  | 1 day after dose administration | 
| Highest pain score on day 0 and 1 |  | 1 day | 
| Time to readiness for discharge from the recovery room |  | 1 day | 
| Complications of block (such as block failure, epidural hematoma, hemo- or pneumothorax and symptoms of toxicity of local anesthetics) |  | 1 day | 
| Patient satisfaction on a scale of 0 (extremely unsatisfied) tot 10 (extremely satisfied) |  | 1 month | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Ultrasound-guided erector spinae plane block, paravertebral block