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Complete Antethoracic Block for Analgesia After Modified Radical Mastectomy: A Case Report

Takahashi, Hidemasa MD; Suzuki, Takeo MD, PhD

doi: 10.1213/XAA.0000000000000480
Case Reports: Case Report
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Complete antethoracic block for modified radical mastectomy is a composite block comprising the antethoracic medial, antethoracic inferior, and antethoracic lateral blocks. The puncture targets of all components are easy to identify, and the risk of complications such as pneumothorax is low. Our patient was a 72-year-old woman undergoing modified radical mastectomy for breast cancer. After induction of general anesthesia, but before surgical incision, she received a complete antethoracic block for anesthesia, which also provided good analgesia postoperatively. We believe that complete antethoracic block is suitable for postoperative analgesia in patients undergoing this surgery.

From the Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.

Accepted for publication November 17, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Hidemasa Takahashi, Department of Anesthesiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan, 4-23-15, Koto-bashi, Sumida-ku, Tokyo 130–8575, Japan. Address e-mail to bokutouma@gmail.com.

Postoperative pain is a common complaint after breast surgery.1 Therefore, postoperative analgesia after this procedure is of interest to anesthesiologists. The pectoral nerve block (types 1 and 2) is an easy, safe, and novel peripheral nerve block for breast surgery and has been reported as a substitute for thoracic paravertebral block and epidural analgesia by Blanco.2,3 The pectoral nerve block affects the lateral and medial pectoral nerves, lateral branches of the intercostal nerves (from T2 to T4 with variable spread to T6), the long thoracic nerve, and the intercostobrachial nerve.3 However, this procedure does not sufficiently block the anterior branches of the intercostal nerves (from T2 to T6) or the lateral branches of the intercostal nerves (from T5 to T6); therefore, postoperative analgesia of the internal and inferior mammary area may be insufficient. Thus, we believe that the pectoral nerve block alone is not suitable for postoperative analgesia in patients undergoing modified radical mastectomy.

We devised the complete antethoracic block to provide analgesia over the entire anterior thoracic wall. The complete antethoracic block is a composite block comprising the antethoracic medial, antethoracic inferior, and antethoracic lateral blocks. These affect multiple anterior branches of the intercostal nerves, the anterior and lateral branches of the intercostal nerves (T5 and T6), and the pectoral nerves, lateral branches of the intercostal nerves, the long thoracic nerve, and the intercostobrachial nerve, respectively.2–4 For the sake of uniform terminology, we here refer to the pectoral nerve block as the antethoracic lateral block. Herein, we report a case in which the complete antethoracic block was used successfully.

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CASE DESCRIPTION

A 72-year-old woman was diagnosed with breast cancer in the 1 o’clock position of the right breast. She was scheduled to undergo modified radical mastectomy with sentinel node dissection. We obtained approval for the present study from the ethics committee of the Tokyo Metropolitan Bokutoh Hospital. Before the study, the patient provided informed, written consent to publish her case. This manuscript adheres to the applicable EQUATOR guidelines (http://www.equator-network.org).

After admission into the operating room, general anesthesia was induced with propofol (controlled infusion target of 3 μg/mL), rocuronium (30 mg), and remifentanyl (0.15 μg/kg/min). After insertion of a laryngeal mask airway for airway management, the complete antethoracic block was administered under ultrasound guidance using a linear probe attached to the Noblus ultrasound system (Hitachi Aloka Medical, Ltd, Tokyo, Japan) with the patient in the supine position (technique described below). Thereafter, a modified radical mastectomy was performed. During the procedure, anesthesia was maintained with propofol and remifentanyl. Irrespective of the analgesic effect of the present block, remifentanyl was routinely administered at 0.1 μg/kg/min.

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Administration of the Complete Antethoracic Block

The target area was cleaned with a solution of 0.5% chlorhexidine in alcohol. For the antethoracic lateral block (pectoral nerve block types 1 and 2), 0.2% ropivacaine (20 mL; AstraZeneca, Wilmington, DE) was injected between the pectoralis major and pectoralis minor muscles. Another dose of 0.2% ropivacaine (20 mL) was injected between the pectoralis minor and serratus anterior muscles.

For the antethoracic medial block, the linear probe was placed slightly outside the lateral edge of the sternum so that the cross-section of the fourth rib was clearly visible (Figure 1). The needle was inserted in the plane of the ultrasound beam in a caudal to cephalad direction and advanced until it reached the surface of the fourth rib. After placement of the needle tip was confirmed by injecting approximately 2 mL of saline and visualizing the spread of saline between the surface of the fourth rib and the pectoralis major muscle, 20 mL of 0.2% ropivacaine was injected. The spread of the local anesthetic was monitored in every direction by ultrasound (Figures 2 and 3).

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

Figure 5.

Figure 5.

For the antethoracic inferior block, the linear probe was placed parallel to the sixth rib at the inferior border of breast so that the surface of the rib was clearly visible (Figure 1). The needle was inserted in the plane of the ultrasound beam in a medial to lateral direction and advanced to the surface of the rib. After placement of the needle tip was confirmed by injecting about 2 mL of saline and visualizing the spread of saline between the surface of the rib and the pectoralis major muscle, 20 mL of 0.2% ropivacaine was injected. The spread of the local anesthetic was monitored in every direction by ultrasound (Figures 4 and 5).

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RESULTS

We describe the successful use of a novel composite block called the complete antethoracic block for postoperative analgesia in a patient undergoing modified radical mastectomy. The patient’s postoperative course was uneventful, and she was discharged without the need for analgesics. Her overall experience with pain control was satisfactory.

We have performed the complete antethoracic block without any complications, including pneumothorax, in 53 patients receiving modified radical mastectomy. Moreover, all patients were satisfied with the extent of postoperative pain control. Supplemental analgesics were not required in about half of cases (26 of 53, 49.1%). If necessary, we provided pentazocine or flurbiprofen axetil as a supplemental analgesic. In such cases, the average time to request an analgesic was 3 hours 15 minutes from the end of surgery.

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DISCUSSION

The pectoral nerve block alone is not sufficient to provide analgesia in the internal and lower mammary areas, although this is necessary after modified radical mastectomy. The present technique, the complete antethoracic block, comprises the antethoracic medial, antethoracic inferior, and antethoracic lateral blocks, affecting, respectively, the multiple anterior branches of the intercostal nerves, the anterior and lateral branches of the intercostal nerves (T5 and T6), and the pectoral nerves, lateral branches of the intercostal nerves, the long thoracic nerve, and the intercostobrachial nerve. This block provided postoperative analgesia over the internal mammary area, inferior mammary area, outer mammary area, and axilla (Figure 6).3–5 Therefore, we believe that this method is suitable for postoperative analgesia in patients undergoing modified radical mastectomy. It may also be useful during breast-conserving surgery in which the incision is located near the areola because the mammary papilla is abundantly supplied by the anterior and lateral branches of the intercostal nerves.5

Figure 6.

Figure 6.

Recently, the transversus thoracic muscle plane block has been reported to provide analgesia over the internal mammary area.6–8 However, because the puncture target is difficult to identify under ultrasound guidance and because the injection site is close to the pleura, which poses a risk of pneumothorax, this technique is difficult, and some practitioners do not feel comfortable performing it.4 In contrast, the puncture targets for the complete antethoracic block (ie, the superficial layer or points close to the surface of the ribs) are easily identifiable under ultrasound guidance and thus present a low risk of complications such as pneumothorax.

This case report has 2 limitations. First, the complete antethoracic block is fundamentally a single-injection, not continuous, technique. This makes it difficult to achieve complete pain relief during the entire postoperative course. Although the present block is superior to the pectoral nerve block alone in its clinical analgesic effect for modified radical mastectomy, there is little difference in the proportion of patients requiring supplemental analgesics between those receiving the pectoral nerve block alone and those receiving the complete antethoracic block (31 of 53, 58.5% vs 26 of 53, 49.1%, respectively). Second, we did not compare the analgesic effect of complete antethoracic block with that of the paravertebral nerve block, which is considered the gold standard regional anesthesia technique for patients undergoing breast surgery. Therefore, it remains to be established that complete antethoracic block definitely provides superior analgesia for modified radical mastectomy. However, our block has some advantages over other analgesia; it can be performed under general anesthesia in the supine position, and it has a low risk of pneumothorax or vascular puncture because the puncture targets lie on rib surfaces. Finally, this block is easily performed under ultrasound guidance because the puncture targets are superficial. Therefore, we believe that all anesthesiologists and patients would be more comfortable if the complete antethoracic block was administered. In future studies, it will be necessary to compare the analgesic effect of complete antethoracic block with that of the paravertebral nerve block.

In conclusion, we believe that the complete antethoracic block is suitable for postoperative analgesia in patients undergoing modified radical mastectomy and recommend its wide adoption for this type of surgery.

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ACKNOWLEDGMENTS

The authors thank Ms Chisato Takubo, our illustrator for Figures 1 and 6.

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DISCLOSURES

Name: Hidemasa Takahashi, MD.

Contribution: This author helped conceive and design the study, acquire, analyze and interpret the data, and write and edit the manuscript.

Name: Takeo Suzuki, MD, PhD.

Contribution: This author helped conceive and design the study, acquire the data, and revise the manuscript.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

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