Breast Cancer

, Volume 25, Issue 2, pp 185–190 | Cite as

Local anesthetic delivery via surgical drain provides improved pain control versus direct skin infiltration following axillary node dissection for breast cancer

  • Muska Khpal
  • James R. C. Miller
  • Zika Petrovic
  • Delilah Hassanally
Original Article



Axillary node dissection has a central role in the surgical management of breast cancer; however, it is associated with a significant risk of lymphoedema and chronic pain. Peri-operative administration of local anesthesia reduces acute and persistent post-surgical pain, but there is currently no consensus on the optimal method of local anesthetic delivery.


Patients undergoing axillary dissection for breast cancer were randomly assigned to receive a one-off dose of levobupivacaine 0.5% (up to 2 mg/kg) following surgery, either via the surgical drain or by direct skin infiltration. Post-operative pain control at rest and on shoulder abduction was assessed using a numerical rating scale. Total analgesia consumption 48 h after surgery was also recorded.


Pain scores were significantly lower when local anesthesia was administered via surgical drain at both 3 and 12 h after surgery; this trend extended to 24 h post-operatively. However, pain scores on shoulder abduction did not differ at the 12 or 24 h time points. No differences were found in the total analgesia consumption or length of hospital stay between treatment groups.


This study demonstrates that local anesthetic delivery via a surgical drain provides improved pain control compared to direct skin infiltration following axillary node dissection. This is likely to be important for the management of acute pain in the immediate post-operative period; however, further studies may be required to validate this in specific patient subgroups, e.g., breast-conserving surgery versus mastectomy.


Breast neoplasms Lymph node excision Anesthesia, local Pain, post-operative 



We thank Medway Maritime Foundation Trust for their support and facilities and the research team for their help with protocol development, power calculation, and ethics approval. We further thank Miss Nasreen Davarpanah and Mr. Ahmed Ibrahim for their support in the initial stages of the study, and the Breast Surgery Nurses for their assistance with patient recruitment and data collection.

Author contribution

MK: PI of the investigation, study design and protocol, data analysis and paper writing. JRCM: Data analysis and paper writing. ZP: Co-supervisor, advised on study design and protocol. DH: Project supervision, advised on study design and protocol, organized patient recruitment and data collection, and performed axillary node dissection.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Tryggvadóttir L, Gislum M, Bray F, Klint A, Hakulinen T, Storm HH, et al. Trends in the survival of patients diagnosed with breast cancer in the Nordic countries 1964–2003 followed up to the end of 2006. Acta Oncol. 2010;49:624–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Mejdahl MK, Andersen KG, Gärtner R, Kroman N, Kehlet H. Persistent pain and sensory disturbances after treatment for breast cancer: 6 years nationwide follow-up study. BMJ. 2013;346:f1865.CrossRefPubMedGoogle Scholar
  3. 3.
    Smith HS, Wu SX. Persistent pain after breast cancer treatment. Ann Palliat Med. 2012;1:182–94.PubMedGoogle Scholar
  4. 4.
    Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Arch Phys Med Rehabil. 2006;87:S96–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain. 2003;104:1–13.CrossRefPubMedGoogle Scholar
  6. 6.
    Andersen KG, Duriaud HM, Jensen HE, Kroman N, Kehlet H. Predictive factors for the development of persistent pain after breast cancer surgery. Pain. 2015;156:2413–22.CrossRefPubMedGoogle Scholar
  7. 7.
    Belfer I, Schreiber KL, Shaffer JR, Shnol H, Blaney K, Morando A, et al. Persistent postmastectomy pain in breast cancer survivors: analysis of clinical, demographic, and psychosocial factors. J Pain. 2013;14:1185–95.CrossRefPubMedGoogle Scholar
  8. 8.
    Tasmuth T, Kataja M, Blomqvist C, von Smitten K, Kalso E. Treatment-related factors predisposing to chronic pain in patients with breast cancer—a multivariate approach. Acta Oncol. 1997;36:625–30.CrossRefPubMedGoogle Scholar
  9. 9.
    Hickey OT, Burke SM, Hafeez P, Mudrakouski AL, Hayes ID, Shorten GD. Severity of acute pain after breast surgery is associated with the likelihood of subsequently developing persistent pain. Clin J Pain. 2010;26:556–60.CrossRefPubMedGoogle Scholar
  10. 10.
    Fassoulaki A, Melemeni A, Staikou C, Triga A, Sarantopoulos C. Acute postoperative pain predicts chronic pain and long-term analgesic requirements after breast surgery for cancer. Acta Anaesthesiol Belg. 2008;59:241–8.PubMedGoogle Scholar
  11. 11.
    Fassoulaki A, Triga A, Melemeni A, Sarantopoulos C. Multimodal analgesia with gabapentin and local anesthetics prevents acute and chronic pain after breast surgery for cancer. Anesth Analg. 2005;101:1427–32.CrossRefPubMedGoogle Scholar
  12. 12.
    Abdelsattar JM, Boughey JC, Fahy AS, Jakub JW, Farley DR, Hieken TJ, et al. Comparative study of liposomal bupivacaine versus paravertebral block for pain control following mastectomy with immediate tissue expander reconstruction. Ann Surg Oncol. 2016;23:465–70.CrossRefPubMedGoogle Scholar
  13. 13.
    Andreae MH, Andreae DA. Local anesthetics and regional anesthesia for preventing chronic pain after surgery. Cochrane Database Syst Rev. 2012;10:CD007105.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Vigneau A, Salengro A, Berger J, Rouzier R, Barranger E, Marret E, et al. A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection. BMC Anesthesiol. 2011;11:23.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lu TJ, Chen JH, Hsu HM, Wu CT, Yu JC. Efficiency of infiltration with bupivacain after modified radical mastectomy. Acta Chir Belg. 2011;111:360–3.CrossRefPubMedGoogle Scholar
  16. 16.
    Albi-Feldzer A, Mouret-Fourme EE, Hamouda S, Motamed C, Dubois PY, Jouanneau L, et al. A double-blind randomized trial of wound and intercostal space infiltration with ropivacaine during breast cancer surgery: effects on chronic postoperative pain. Anesthesiology. 2013;118:318–26.CrossRefPubMedGoogle Scholar
  17. 17.
    Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;2010(340):c332.CrossRefGoogle Scholar
  18. 18.
    Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1988;14:9–17.PubMedGoogle Scholar
  19. 19.
    Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93:1123–33.CrossRefPubMedGoogle Scholar
  20. 20.
    Staats PS. The effect of pain on survival. Anesthesiol Clin N Am. 2003;21:825–33.CrossRefGoogle Scholar

Copyright information

© The Japanese Breast Cancer Society 2017

Authors and Affiliations

  1. 1.Anesthetics and Surgical DepartmentMedway Maritime Foundation TrustGillinghamUK
  2. 2.UCL Medical SchoolUniversity College LondonLondonUK
  3. 3.Anesthetics DepartmentUniversity College HospitalLondonUK

Personalised recommendations