Pain Free Breast Cancer Surgery – What’s New In Anesthesia

Note by Dr Suraj Manjunath: This is a guest post by Dr Arul Prakasham, consultant anesthesiologist at Manipal Hospital, Miller’s Road (formerly Vikram Hospital), Bangalore.  The article discusses the latest advances in anesthesia techniques in breast cancer surgery, and how these techniques minimize short-term as well as long-term pain associated with the surgery.  Dr Arul is a highly competent anesthesiologist, who has a special interest in image-guided regional anesthesia techniques.

Breast cancer is the most common cancer among Indian women. Surgery is an important part of breast cancer treatment.  Surgical options include Breast Conservation Surgery (where the breast is preserved) and Mastectomy (where the breast is removed) with or without plastic surgical reconstruction of the breast. Surgery for breast cancer can sometimes lead to significant postoperative pain, which if not managed well, can cause long-standing post-surgical pain.

Conventionally, pain after breast cancer surgery has been managed using painkiller medications given orally or as intravenous/intramuscular injections – usually a suitable combination of paracetamol, anti-inflammatories, and opioids. While these modern painkiller medications are quite effective, they may not completely eliminate pain.  In addition, not all painkillers are suitable for everybody and may also have side effects like nausea, vomiting, drowsiness, etc.

More recently, interventional anesthesia techniques like Thoracic Epidural and Thoracic Paravertebral Block are being used in addition to painkiller medications.  These entail the injection of local anesthetics near the spinal cord at the time of surgery to block the pain signals from reaching the brain.  These techniques further decrease post-operative pain, and also reduce the doses of conventional painkillers required. However, since these injections are given close to the spine, they may on rare occasions cause complications like difficulty in breathing or a fall in blood pressure.

The last decade can be described as the ERA OF ULTRASOUND-GUIDED REGIONAL ANESTHESIA.  This is a technique where, once the patient is under general anesthesia, very small amounts of local anesthetic are injected in specific locations near the breast using real-time ultrasound scanning.  This technique blocks the pain signals during surgery, but at locations closer to the breast and away from the spinal cord. As a result, post-operative pain is significantly reduced, while at the same time, complications are minimal.  Some described methods of ultrasound-guided regional anesthesia are:

  1. PECS 1 (Rafael Blanco 2011)
  2. PECS 2 (Rafael Blanco 2012)
  3. SAP (Rafael Blanco 2013)
  4. ESB (Ferrero Et al 2016)

To summarize, breast cancer surgery in today’s era can be performed with minimal to no pain after surgery, making the surgical outcome pleasant. To achieve this, close coordination by the surgeon and anesthesiologist, as well as a detailed discussion with the patient is essential.  Each individual patient can be provided the most suitable and personalized pain management solution.

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