Abstract
Introduction
Paravertebral block (PVB) has emerged as a viable strategy for improving postoperative outcomes in breast surgery; however, it is unclear whether these benefits extend to recipients of post-mastectomy reconstruction (PMR).
Methods
A systematic search of the PubMed, EMBASE, Web of Science and Cochrane Library electronic databases was conducted for all studies matching the a priori inclusion criteria (inception to 1 March 2017). Independent assessment by two reviewers, in stages, of the title/abstract and full text was performed. Data relating to study design, patient characteristics, PVB medications and technique, and outcomes, including pain, opioid consumption, length of stay (LOS), postoperative nausea and vomiting (PONV), and PVB-related complications was abstracted.
Results
Of the 1243 identified articles, nine met the inclusion criteria, accounting for 936 patients (PVB, n = 518; non-PVB, n = 418) in two randomized controlled trials (RCT) and seven retrospective cohort studies. Of these studies, six described PVB for prosthetic PMR, and three described PVB for autologous PMR. Overall, there is a subtle trend towards improved pain control, less opioid requirement and shorter LOS, while PONV was largely unchanged in patients receiving PVB for PMR. In two studies, technical failure was reported at 7.4 and 10%, although no study reported a PVB-related complication. Study quality varied, and risk of bias in the included studies was high. Heterogeneity precluded a meta-analysis.
Conclusions
Although recent reports and RCTs advocate for PVB use in PMR, our review highlights significant heterogeneity and knowledge gaps that must be addressed in order for PVB to become part of the optimal anesthetic protocol in PMR.
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References
Terkawi AS, Tsang S, Sessler DI, et al. Improving Analgesic Efficacy and Safety of Thoracic Paravertebral Block for Breast Surgery: A Mixed-Effects Meta-Analysis. Pain Physician. 2015;18:E757–80.
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia. 2010;105:842–52.
Desai S, Jena AB. Do celebrity endorsements matter? Observational study of BRCA gene testing and mastectomy rates after Angelina Jolie’s New York Times editorial. BMJ. 2016;355:i6357.
Donovan CA, Bao J, Gangi A, et al. Bilateral Mastectomy as Overtreatment for Breast Cancer in Women Age Forty Years and Younger with Unilateral Operable Invasive Breast Cancer. Annals of Surgical Oncology. 2017. 24(8):2168–2173.
Murphy R, Wahhab S, Rovito P, et al. Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy. Ann Plast Surg. 2003;2003:333–8.
Roughton MC, DiEgidio P, Zhou L, Stitzenberg K, Meyer AM. Distance to a Plastic Surgeon and Type of Insurance Plan Are Independently Predictive of Postmastectomy Breast Reconstruction. Plastic and Reconstructive Surgery. 2016;138:203e–11e.
Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plastic and Reconstructive Surgery. 2000;106:1014–25; discussion 26-7.
Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ journal of surgery. 2005;75:940–7.
Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plastic and Reconstructive Surgery. 2013;131:15–23.
Jaffe SM, Campbell P, Bellman M, Baildam A. Postoperative nausea and vomiting in women following breast surgery: an audit. European Journal of Anaesthesiology. 2000;17:261–4.
Wolf O, Clemens MW, Purugganan RV, et al. A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction. Plastic and Reconstructive Surgery. 2016;137:660e–6e.
Temple-Oberle C, Shea-Budgell M, Tan M, et al. Concensus Review of Optimal Perioperative Care in Breast Reconstruction Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plastic and Reconstructive Surgery. 2017;139:1056e–71e.
Parikh RP, Sharma K, Guffey R, Myckatyn TM. Preoperative Paravertebral Block Improves Postoperative Pain Control and Reduces Hospital Length of Stay in Patients Undergoing Autologous Breast Reconstruction after Mastectomy for Breast Cancer. Annals of Surgical Oncology. 2016;23:4262–9.
Heesen M, Klimek M, Rossaint R, Imberger G, Straube S. Paravertebral block and persistent postoperative pain after breast surgery: meta-analysis and trial sequential analysis. Anaesthesia. 2016;71:1471–81.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology. 2009;62:e134.
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology and Community Health. 1998;52:377–84.
Silverman SR, Schertz LA, Yuen HK, Lowman JD, Bickel CS. Systematic review of the methodological quality and outcome measures utilized in exercise interventions for adults with spinal cord injury. Spinal Cord. 2012;50:718–27.
Buggy DJ, Kerin MJ. Paravertebral analgesia with levobupivacaine increases postoperative flap tissue oxygen tension after immediate latissimus dorsi breast reconstruction compared with intravenous opioid analgesia. Anesthesiology. 2004;100:375–80.
Coopey SB, Specht MC, Warren L, Smith BL, Winograd JM, Fleischmann K. Use of preoperative paravertebral block decreases length of stay in patients undergoing mastectomy plus immediate reconstruction. Annals of Surgical Oncology. 2013;20:1282–6.
Abdelsattar J, Boughey J, Aodhnait F, et al. Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction. Annals of Surgical Oncology. 2016;23:465-70.
Glissmeyer C, Johnson W, Sherman B, Glissmeyer M, Garreau J, Johnson N. Effect of paravertebral nerve blocks on narcotic use after mastectomy with reconstruction. Am J Surg 2015;209:881-3.
Aufforth R, Jain J, Morreale J, Baumgarten R, Falk J, Wesen C. Paravertebral blocks in breast cancer surgery: is there a difference in postoperative pain, nausea, and vomiting? Annals of Surgical Oncology. 2012;19:548-52.
Unkart JT, Padwal JA, Ilfeld BM, Wallace AM. Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review. Anesthesiology and Pain Medicine. 2016;6(5):e39476.
Fahy AS, Jakub JW, Dy BM, et al. Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Annals of Surgical Oncology. 2014;21:3284–9.
Vila H, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol. 2007;20:316–18.
Naja Z, Lonnqvist P. Somatic paravertebral nerve blockade. Incidence of failed block and complications. Anaesthesia. 2001;56:1184–8.
Richardson J, Lonnqvist P. Thoracic paravertebral block. Br J Anaesth. 1998;81:230–8.
Tahiri Y, Tran DQ, Bouteaud J, et al. General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2011;64:1261-9.
Shea BJ, Hamel C, Wells GA, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. Journal of Clinical Epidemiology. 2009;62:1013–20.
Samargandi OA, Hasan H, Thoma A. Methodologic Quality of Systematic Reviews Published in the Plastic and Reconstructive Surgery Literature: A Systematic Review. Plastic and Reconstructive Surgery. 2016;137:225e–36e.
Taichman DB, Sahni P, Pinborg A, et al. Data Sharing Statements for Clinical Trials - A Requirement of the International Committee of Medical Journal Editors. N Engl J Med. 2017;376:2277-9.
Ng TT, McGory ML, Ko CY, Maggard MA. Meta-analysis in surgery: methods and limitations. Archives of Surgery. 2006;141:1125-30; discussion 31.
Egger M, Smith GD. Meta-Analysis. Potentials and promise. BMJ. 1997;315:1371–4.
Chiappelli F, Caldeira Brant X, Neagos N, Oluwadara O, Ramchandani M, eds. Evidence-Based Practice: Toward Optimizing Clinical Outcomes. Berlin: Springer-Verlag Berlin Heidelberg; 2010.
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The authors wish to thank Charalampos Siotos for his technical assistance in preparing this article.
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Offodile, A.C., Aycart, M.A. & Segal, J.B. Comparative Effectiveness of Preoperative Paravertebral Block for Post-Mastectomy Reconstruction: A Systematic Review of the Literature. Ann Surg Oncol 25, 818–828 (2018). https://doi.org/10.1245/s10434-017-6291-7
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DOI: https://doi.org/10.1245/s10434-017-6291-7