Overview of Regional Anesthesia for Breast Reconstruction
Breast cancer is the most common type of cancer in women worldwide. In fact, it’s the second leading cause of cancer deaths, right after lung cancer. Alarmingly, around 17 million new cases are reported each year. The earlier a woman is diagnosed with breast cancer, the higher the risk of dying from it. This is because early onset breast cancer tends to be more aggressive than those occurring later in life.
Breast cancer stats in the U.S predicted that 42,170 women were expected to pass away from the disease in 2020. Death from breast cancer is often not due to the primary or original tumor, but due to its recurrence or spread to other parts of the body.
Surgery, such as removing the breast (mastectomy), is typically the primary way to treat breast cancer that can be surgically removed. This is important in controlling the cancer if it has spread or become advanced.
After a woman has a mastectomy, she should be offered the option to recreate the breast shape through reconstruction. This is a recommendation from the National Institute for Health and Clinical Excellence (NICE). However, the method or type of reconstruction is chosen based on the patient’s and surgeon’s preference. Roughly 10% to 20% of patients experience severe pain after the operation, which can turn into chronic or long-term pain, often referred to as postmastectomy pain syndrome.
Proper pain management is essential for a patient’s recovery after the surgery. That’s why follow-ups with a pain management doctor can help those dealing with postmastectomy pain syndrome.
Adding regional anesthesia techniques to general anesthesia during breast reconstruction surgery can actually decrease the pain experienced after the operation. This proven approach is helpful for controlling severe pain after surgery, reducing the need for pain medicine, speeding up recovery, and shortening the hospital stay.
There are main techniques of administering regional anesthesia during breast reconstruction surgery that will be detailed in the mentioned documents. These include the paravertebral block, intercostal nerve block, erector spinae plane block (EPSB), pectoralis nerve block (Pecs), and serratus anterior plane blocks.
Anatomy and Physiology of Regional Anesthesia for Breast Reconstruction
The human body can be numbed for medical procedures through different techniques that deliver anesthesia to specific nerves. This will depend on the type of block the doctor needs to perform for the procedure:
1. Paravertebral Block: This block, rediscovered in the late 1970s, involves injecting anesthesia around the spinal nerves that emerge from the spine. It can cause numbness over a whole side of the body and is a good technique to reduce post-operation pain.
2. Intercostal Nerve Block: First described in 1907, this block aims at numbing the nerves in between the ribs, which are responsible for feeling and movement in different parts of your body. When local anesthetic is injected in these areas, it can help manage pain during and after chest or abdomen surgeries.
3. Erector Spinae Plane Block: This technique is used to numb the nerves between the spine and the rib cage. The local anesthesia blocks the nerves that receive sensations from the front, back and sides of your chest or abdomen. Current studies show the anesthesia can spread quite widely from the injection site, leading to local numbness in several areas.
4. Pectoralis Nerve Block: This block is used to numb nerves in the chest and upper arm area. It is primarily used for procedures that involve the chest muscles. The anesthesia is injected between various layers of muscles in your chest to numb the area.
5. Serratus Anterior Plane Blocks: This method, first described in 2013, involves the injection of anesthesia in between muscles in your chest and side area. The aim is to block sensation in the nerves that serve the muscles in the lateral part of the chest, enabling the management of pain in this area.
Each of these blocks reduces pain in different parts of your body and is chosen based on the surgical procedure you need to undergo.
Why do People Need Regional Anesthesia for Breast Reconstruction
Research shows that around two-thirds of women who undergo breast cancer surgery experience long-term pain afterwards.
Recent studies suggest that using regional anesthesia, which numbs a specific part of the body, together with general anesthesia, which makes you unconscious, can help manage severe pain after surgery. This combination may prevent the pain from becoming chronic and reduce the need for opioids, which are strong pain medications that can have side effects such as nausea, vomiting, difficulty breathing, and hallucinations, especially in older patients. Using regional anesthesia can help patients recover more quickly and lessen the time they need to stay in the hospital.
Many doctors who specialize in anesthesia now use regional anesthesia often in their practice when treating breast cancer because of its benefits. Research even suggests that regional anesthesia could reduce the likelihood of cancer coming back after treatment. One study found that using a medication called lignocaine to numb the nerves in the chest provided better pain relief after surgery compared to not using regional anesthesia. This method also seemed to lower the release of certain markers in the body that can encourage cancer to spread.
Therefore, regional anesthesia can be particularly useful for people who have a history of chronic nerve pain and might already be taking a lot of opioids before their surgery. It can also benefit patients with serious health conditions alongside their cancer, because it might reduce the need for general anesthesia, which can sometimes strain the heart, lungs, and brain.
When a Person Should Avoid Regional Anesthesia for Breast Reconstruction
There are certain reasons why regional anesthesia, which numbs only a specific area of your body, may not be the right choice for some patients:
- Firstly, if a patient doesn’t want to have it, then it won’t be used.
- Secondly, if there’s an infection where the anesthesia would be injected, it’s not safe to proceed.
- Thirdly, if a patient is allergic to the substances used in local anesthesia, an alternative will need to be found.
- Lastly, if a patient is taking blood-thinning medications and either their INR (a measure of blood thickness) is over 1.4 or they haven’t stopped taking the medication long enough before the surgery, as per the American Society of Regional Anesthesia (ASRA) guidelines, then regional anesthesia might be too risky.
Equipment used for Regional Anesthesia for Breast Reconstruction
The various local anesthesia techniques used during breast reconstruction surgery rely on ultrasound guidance to help reduce the risk of nerve damage and a condition called pneumothorax (abnormal collection of air or gas in the chest that can cause lung collapse). These methods often require the following tools:
An ultrasound machine with a high or low frequency probe: This depends on how deep the procedure will be and the size of the patient. The probe is a device that sends out sound waves to visualize the inner structures of the body.
A sterile sleeve and gel: These are used on the ultrasound probe to maintain cleanliness and for better imaging respectively.
A 23 to 25-gauge needle: This small needle is used for numbing the skin before the procedure.
Local anesthetic: This is a substance that numbs a specific area of the body to block pain while the procedure is being performed.
An 80mm B-bevel nerve block needle: This is a special kind of needle used to inject the local anesthetic near the specific nerve to block sensation in a particular body area.
A pack of gauze (4-inch x 4-inch): This is used to stop bleeding or to hold medicine in place.
Chlorhexidine gluconate: This is a solution used to cleanse the skin to reduce the risk of infection.
Sterile gloves and a marking pen: The gloves are for hygiene, and the pen is to mark the location of the procedure.
Who is needed to perform Regional Anesthesia for Breast Reconstruction?
Local or regional anesthesia, which helps numb a specific area of your body, should be given by trained experts capable of handling any unexpected issues that arise. These experts often include anesthetists, who are doctors specializing in pain relief and managing the body’s vital functions. Depending on how stressed or anxious the patient feels, they may also receive sedation, which helps calm them down during the procedure.
It’s also useful to have a specially trained nurse on hand to help the anesthetist. This nurse can assist with the procedure and help manage patient sedation if needed. With the doctor and nurse working together, patients can be assured of their safety and comfort during medical procedures.
Preparing for Regional Anesthesia for Breast Reconstruction
As recommended by the World Health Organization (WHO), before any medical procedure a thorough assessment should be completed. In addition, an evaluation of the patient’s overall health condition and past medical issues should be carried out. This includes reviewing their medical history, doing a physical check-up, assessing their breathing, and analyzing the results of pre-procedure tests.
It is crucial that the patient is made aware of the potential benefits and risks of the regional anesthesia before they give their consent to proceed. Regional anesthesia is the type of anesthesia that numbs a specific area of the body. The potential complications should also be discussed with them.
The medical procedure should be carried out in a clinic that specializes in regional anesthesia. During the procedure, the patient’s vital signs like pulse rate, heart activity, and blood pressure must be continuously monitored. This is in line with the basic anesthesia monitoring standards set by the American Society of Anesthesiologists.
How is Regional Anesthesia for Breast Reconstruction performed
A thoracic paravertebral block is a type of anesthetic procedure that is used to manage pain, typically during or after surgery. Traditionally, this procedure involved feeling for a change in resistance to identify the correct location, but this technique has been replaced in many medical facilities due to failure rates and potential complications. Instead, ultrasound technology is now typically used to guide the procedure, enhancing precision and safety.
In the procedure, medical tools and technologies such as a linear probe are used along with ultrasound equipment to guide the placement of a needle and local anesthetic in the correct location. The needle is initially positioned outside of the body, and then carefully moved toward the area of treatment within the body.
Similarly, local anaesthetic techniques like Erector Spinae Plane Block, Serratus Plane Block, Pectoralis Nerve Block, and Intercostal Nerve Block all make use of ultrasound guidance for accurate and safe delivery of anesthetic drugs. In all these approaches, the area of treatment is first cleaned and sterilised. Then the specific body landmarks and structures are identified via ultrasound, and a needle is carefully guided to the appropriate location. Local anesthetics are then administered to reduce pain and ensure patient comfort. These methods are all part of cutting-edge medicine and are designed to minimise pain, reduce risks, and improve the outcome of medical procedures.
Possible Complications of Regional Anesthesia for Breast Reconstruction
Local or regional anesthesia, used to numb a specific area of the body, requires a deep understanding from the medical team because it can cause potential complications.
Some of these complications may include infections due to sterilization mistakes, bleeding, development of blood clots at the site where the needle was inserted, damage to the nerves, and harmful effects from the local anesthetic. People with a history of blood clotting issues or taking blood thinners should inform their doctor before getting any regional anesthesia. However, with the advancement of technology like ultrasound, these techniques may have a lower risk of damaging nerves or blood vessels.
In some procedures, like a paravertebral and intercostal block (anesthetic injections around the spine and between the ribs), it’s preferred that the patient remains awake due to the risk of having a collapsed lung or nerve damage.
For some nerve blocks, the anesthetic can spread far from where it’s injected, leading to serious complications. For example, some cases show the anesthetic spreading into the spinal cord after intercostal blocks, which is a serious complication.
Research also shows that there may be a higher risk of damaging blood vessels and developing a collapsed lung with a double-sided paravertebral block compared to a one-sided block.
Other potential risks could include unintentional puncture of a blood vessel, low blood pressure, or the spread of the anesthetic into the spinal cord.
In rare cases, lung bleeding has been reported in patients who got a paravertebral block for chest surgery. Some patients have also experienced what’s called “Horner’s syndrome” (which causes droopy eyelids and reduced pupil size) after getting unilateral paravertebral anesthesia for breast cancer surgery.
It’s crucial for anesthesiologists to be aware of these potential complications and understand the patient’s anatomy before any regional anesthesia procedure. This will help prevent complications and ensure a safe and effective procedure.
What Else Should I Know About Regional Anesthesia for Breast Reconstruction?
Breast cancer surgery with reconstruction can be a long and stressful procedure that may result in complications, including nerve damage. This could lead to severe pain after the surgery, and in some cases, conditions like phantom breast pain, intercostobrachial neuralgia (pain in the upper arm and chest wall), or neuropathic pain (chronic pain resulting from damage to the nervous system).
In some medical centers, patients may continue to experience chronic pain in the surgery site or the same-side upper limb for a year or even longer after breast surgery. Research has found a link between the persistence of chronic pain and how invasive the surgery was, with 49% of cases noted for a mastectomy with reconstruction, 31% for a mastectomy, and 22% for breast reduction. Factors contributing to this chronic pain can include the severity of the initial pain after surgery, the type and extent of the surgical procedure, the involvement of regional lymph nodes (small glands that filter out harmful substances), and the usage of radiotherapy before or after surgery.
Several medical studies have indicated that the application of localized anesthesia (medication to numb a specific part of the body) during breast surgery can help reduce chronic pain. This also helps lower patient complications, thereby reducing their hospital stay by minimizing the need for opioids (strong pain medication). Other than helping manage pain, certain researchers have explored the impact of regional anesthesia techniques on long-term cancer outcomes. For example, there seems to be an association between women receiving a specific kind of regional anesthesia (paravertebral) and a decrease in cancer recurrence.
Postoperative complications following cancer surgery might delay cancer therapy, which could negatively affect the potential for cancer recurrence. Certain studies have shown that regional anesthesia suppresses the stress response to surgery and reduces a period of weakened immunity post-surgery because it reduces the use of general anesthetics and opioids. This allows the immune system to better eliminate any remaining cancer cells.
Research studies have indicated a significant reduction in the activity of specific immune cells in patients who received regional anesthesia along with general anesthesia. However, how this anesthesia affects tumor mediators remains unclear. In animal studies, uncontrolled pain is seen to suppress certain immune cells and aid the spread of cancer.
