Quality assessment of the cohort studies using modified MINORS score yielded a range of 18–22. The most common deficiency was lack of prospective calculation of sample size, likely due to the retrospective nature of these studies. The 2 RCTs were reviewed according to Cochrane’s Risk of Bias tool and deemed to have low bias.
Postoperative Pain Outcomes
Pain scores were reported in 3 studies (Table 2). One study used average Numeric Rating Score (NRS; 0–10 numeric pain rating scale) and 2 studies used the visual analog scale (VAS; 0–10 numeric pain rating scale). Wolf et al. reported significantly lower average NRS scores among PVB patients compared with GA-alone patients for the postoperative intervals of 0–1, 1–3, and 3–6 hours.36
Strazisar et al. and Abdelsattar et al. evaluated pain using the VAS.37,40 Strazisar et al. studied changes in postoperative pain stratified by activity levels. Resting PVB patients had a significantly lower median VAS score compared with GA-alone patients only in the recovery room. However, “on activity” (activity with the upper extremity), PVB patients had significantly lower median pain scores than GA-alone patients at all postoperative time periods (from recovery room to 9 hours, at 3-hour intervals). On activity, median VAS scores on the day of surgery were significantly lower for PVB patients than for GA-alone patients; there was no significant difference in median scores for the first postoperative day between these groups.37 Abdelsattar et al. compared a PVB treatment group to a LB control group, reporting a significantly lower, average VAS pain score only at day 0 among the LB group versus the PVB group. The pain scores were not significantly different for the other postoperative assessment days.40
Opioid Use Outcomes
Opioid use was reported as consumption of narcotics or morphine equivalents (MEs) in 6 of the 7 studies (Table 3). Both RCT studies showed that PVB patients received less postoperative opioids compared with GA-alone patients.36,37 Specifically, Strazisar et al. reported that on average, patients who received PVB with levobupivacaine consumed significantly less piritramide in the first 24 hours after surgery compared with GA-alone patients.37 Wolf et al. reported average, total fentanyl administered preoperatively and intraoperatively, noting that PVB patients were administered less fentanyl compared to patients with GA alone.36
Additionally, 2 retrospective studies showed that PVB patients received less postoperative narcotics compared with the comparator. For patients undergoing bilateral PMR, Fahy et al. reported on average, PVB patients consumed significantly less ME than those given GA alone; however, this difference was not observed in patients undergoing unilateral mastectomy with PMR.41 Aufforth et al. also reported that PVB patients who underwent immediate TE PMR consumed less ME than GA-alone patients during the first postoperative day; however, this difference was not seen between the 2 groups in the recovery room or 0 days following surgery.38
Glissmeyer et al. reported that PVB patients received less ME compared to non-PVB patients; however, no statistical analysis was conducted.39 Lastly, Abdelsattar et al. found that PVB patients consumed a significantly higher average of ME compared to LB-only patients in the postanesthesia care unit (PACU) but had no significant difference in postoperative opioid consumption days 0–2.40
Length Of Stay
Two studies reported LOS as proportion of patients with a LOS less than 36 hours. Abdelsattar et al. reported no significant difference in LOS between the LB group versus the PVB group.40 Similarly, Fahy et al. reported no significant difference in LOS between patients with PVB compared to GA alone/non-PVB patients, following a multivariate analysis.41
One study reported LOS in hours while 2 studies measured LOS in days. Coopey et al. reported that, on average, patients undergoing prosthetic PMR with PVB had a significantly shorter LOS compared to the non-PVB group, regardless of laterality (unilateral versus bilateral) or type (TE versus immediate implant placement) of PMR.33 Strazisar et al. reported that there was no significant difference in LOS between the local PVB group and the standard treatment group.37 Glissmeyer et al. reported PVB patients had shorter LOS (1.3 days) compared to those without PVB (2 days); however, this study did not perform a statistical analysis to determine significance.39
Lastly, Wolf et al. reported that on general LOS, no significant difference in length of hospital stay was found between the PVB treatment and control groups.36
PONV and Antiemetic Medication
Wolf et al. investigated postoperative nausea scores (reported as NRS ranging from 0 to 10), reporting no significant difference in average scores between the PVB group and the GA-alone group at various intervals (immediately following surgery and up to 22 hours postoperatively). Additionally, they reported no significant difference in the average number of vomiting episodes in the PACU or at time of discharge between the 2 groups.36
Fahy et al. used postoperative antiemetic administration as a proxy for postoperative nausea. Analyses showed the PVB group receiving significantly less antiemetics than the GA-alone group, even after controlling for laterality of PMR.41 Coopey et al. reported a significantly lower proportion of patients with postoperative nausea in the PVB group compared to the non-PVB group, but found no significant difference in the proportion of patients with postoperative vomiting. However, this study did not quantify antiemetic use between the 2 groups.33
Abdeslsattar et al. reported a significantly lower proportion of LB patients using antiemetic medication one day following PMR compared to PVB patients.40 Strazisar et al. also reported that PVB patients on average consumed significantly less metoclopramide than GA patients.37 Lastly, Wolf et al. found no significant difference in average consumption of antiemetics among PVB patients compared to GA-alone patients.36
In light of the US opioid epidemic, there is an intense focus on finding alternatives to effective postoperative pain control following surgery.25,42–46 In 2016, the CDC released clinical guidelines for chronic pain management, aiming to decrease misuse, abuse, and overdose from opioids. However, there remains minimal guidance for physicians on the management of acute pain, specifically in the perioperative and acute postoperative setting.47,48 Regional anesthetic techniques, such as PVBs, are an example of a possible method to reducing postoperative pain and initial narcotic utilization with well described, minimal complications.49 This review demonstrates that this technique not only may favor positive postoperative outcomes, but also displays the heterogeneity of existing studies and their slightly conflicting results.
PVB was shown to positively reduce acute postoperative pain and reduce PONV/antiemetic medication consumption in IBR patients. However, there is not enough evidence to draw strong conclusions regarding PVB’s impact on opioid consumption and LOS. Two of 3 studies reporting pain show PVB reduces acute postoperative pain (during the recovery room and within the first postoperative day following PMR) compared to GA alone.36,37 Furthermore, 4 of 5 studies indicate significant decreases in postoperative nausea and antiemetic consumption. There is positive evidence of PVB’s impact on opioid consumption. Lastly, there is not enough evidence to state PVB significantly reduces LOS with 4 of 6 studies showing no significant difference between PVB and non-PVB groups.36,37,40,41
The 2 RCTs show an overall significant decrease in acute postoperative opioid consumption,37,38 a finding supported by 2 retrospective studies also indicating significant decreases in opioid consumption among the PVB group.38,41 However, 1 study showed a decrease in opioid consumption but lacked statistical analysis,39 while another study conversely reports significantly higher consumption of opioids in the PVB group versus the control group receiving LB in the PACU.40 Abdelsattar et al did not use contemporary groups for comparison and found no difference in opioid consumption at later postoperative time points. Due to the strength of evidence from the included RCTs in addition to some evidence from observational studies, PVB does seem to reduce acute postoperative opioid consumption.
Several studies have shown that IBR patients are at risk for significant, postoperative pain compared to ABR patients.6,8,50 As such, these patients require more narcotics and other analgesics for their pain management.7,8 Suboptimal pain management is associated with further negative effects: slowed recovery, increased morbidity, prolonged opioid use during and after hospitalization, impaired physical function, and lowered quality of life.8,51,52 Increased, acute postoperative pain is a significant predictor of chronic pain syndromes, which negatively impact quality of life and affects nearly 50% of patients with breast cancer.9–12,53,54 One study reviewed long-term chronic pain, reporting PVB patients had less pain compared to GA alone at 3 months following PMR37; however, the mechanism for developing chronic pain among breast cancer patients following PMR is poorly understood.
Possible factors contributing to the development of chronic pain in this patient population may include: pain due to surgical scars, chest wall pain, upper-arm pain, shoulder discomfort, and/or a neuropathic component that develops into a complex, regional pain syndrome.55 Surgical technique is another possible mechanism for the development of chronic pain in IBR patients. The predominant technique, placement of the implant under the pectoralis muscle, has been associated with increased pain compared to the prepectoral method.6,7 Manipulation of the muscle could lead to higher rates of referred pain7 or muscle spasming.55–57 Lastly, psychological factors and psychological vulnerability to pain perception are significantly associated with greater postoperative pain intensity.58,59
The results of this systematic review support PVB’s value as an alternative to opioids for controlling postoperative pain among IBR patients. However, this review was limited by the quantity and quality of the available literature. The significant heterogeneity in the results prevented the conduct of a meta-analysis. Aufforth et al. found no significant difference in average pain scores on all postoperative days between the PVB and non-PVB groups, whereas Fahy et al. reported no significant difference in average pain scores between their experimental groups, on the day of surgery. However, Aufforth et al. did not specifically distinguish patients who only underwent IBR.38 As well, Fahy et al. did not distinguish between mastectomy only patients versus mastectomy plus reconstruction patients; nor did this study detail the scoring system used.41 For LOS, Aufforth et al. displayed a significantly lower LOS for the PVB group versus the non-PVB group and no significant difference in the proportion of patients with PONV. However, these results refer to all included patients, not simply IBR patients.38
The majority of the included studies were retrospective and observational. Other limitations of reviewed studies include: studies with small sample sizes, use of varying anesthetic agents for PVB injection along with different anesthetics for the control group, the lack of standard postoperative protocols for pain management, lack of controlling for the impact of sentinel lymph node biopsy or axillary lymph node dissection on pain, and different measurement scales for each outcome of interest. An additional limitation is lack of reported costs incurred from using PVB. From a policy perspective, understanding the costs of introducing an intervention is an important factor in considering its overall benefits and should be included in future studies.
In multiple meta-analyses that included patients undergoing an array of breast surgery procedures (from breast-conserving surgery to cosmetic), PVB has been shown to be a superior and effective treatment for postoperative pain management, limiting opioid consumption, and reducing LOS and PONV compared to GA alone.31,32,60,61 However, to draw strong conclusions about PVB’s effectiveness in IBR patients is dependent on further research. A systematic review conducted by Offodile et al. assessing the effectiveness of PVB in PMR (both IBR and ABR) patients was overall consistent with our findings. The review of Offodile et al. was limited by number and quality of included studies (9 studies were included, of which 7 were observational while 2 were RCTs) and heterogeneity of results. Therefore, they reported on the trends of PVB’s efficacy showing some positive impact in improving pain management, decreasing opioid consumption, and reducing LOS while not impacting PONV.62
Despite the limitations, this review is a rigorous synthesis of current literature. Overall, the limited number of studies and heterogeneity of results necessitates further research in examining PVB as an alternative to narcotic, postoperative pain control in the prosthetic PMR patient.
Given the current opioid crisis, there is a growing emphasis on non-narcotic alternatives in the perioperative setting. In prosthetic PMR, PVBs may provide an alternative analgesic approach to improve postoperative pain and enhance recovery. Evidence suggests that PVB reduces acute, postoperative pain, improves PONV, and may have a positive impact on reducing opioid consumption. There is not enough evidence to support that PVB is associated with a decreased LOS. More high-quality studies are needed to assess the effects of PVB on perioperative opioid consumption, quality of recovery, and chronic pain in IBR patients.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.
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