An Observational Analysis about Novel Chest Wall Blocks (PECS and SERRATUS) During Breast Surgery

Special Article - Transplant Surgery

Austin J Surg. 2016; 3(1): 1083.

An Observational Analysis about Novel Chest Wall Blocks (PECS and SERRATUS) During Breast Surgery

Luca Guzzetti¹*, Giorgio Danelli2, Erika Basso Ricci², Vito Torrano³, Gianluca Russo³, Pierfrancesco Fusco4, Paolo Scimia4, Giuseppe Gazzerro5, Antonio Corcione6, Gianluca Cappelleri6 and Andrea Luigi Ambrosoli1

¹Ospedale di Circolo Varese, Anesthesia and Intensive Care, Italy

²Ospedale Cremona, Anesthesia and Intensive Care, Italy

³Ospedale Lodi, Anesthesia and Intensive Care, Italy

4Ospedale Sansalvatore L’Aquila, Anesthesia and Intensive Care, Italy

5Ospedale dei Colli Napoli, Anesthesia and Intensive Care, Italy

6Ospedale Gaetano Pini Milano, Anesthesia and Intensive Care, Italy

*Corresponding author: Luca Guzzetti, Anesthesia and Palliative Care University Hospital Circolo Varese, V.le Borri, 21100 Varese, Italy

Received: May 16, 2016; Accepted: June 01, 2016; Published: June 03, 2016


Introduction: Nowadays breast surgery is one of the common surgical procedure associate with moderate and severe sequences in term of postoperative pain. Recently new chest wall blocks emerged and appear an optimal solution to decrease acute postoperative pain onset with its chronicization.

Materials and Methods: Five Italian Hospitals participated to an observational study. Women submitted to breast surgery performed with the use of chest wall blocks were enrolled to the study. We analyzed the postoperative pain onset in the first 48 hours, the perioperative complications, the perioperative opioids use and postoperative nausea and vomiting rate.

Results: Our multicenter observational analysis yielded 279 women that performed breast surgery addicted with a chest wall blocks in a period of six month. The procedures analyzed were Ductectomy, Lymphadenectomy, and Mastectomy with lymphadenectomy, Mastoplasty, Nodulectomy, Breast plastic, Quadrantectomy with SLNB (Sentinel Lymph Node Biopsy), Quadrantectomy with SLNB and lymphadenectomy. Mastectomy with lymphadenectomy registered the worse postoperative pain at 6 postoperative hours (3 (1,25- 4,75[0-8])). The postoperative rescue opioids use was encountered mainly after mastoplasty (16,6%) and lymphadenectomy (16,6%). Postoperative nausea and vomiting rate was 5,01% (all procedures together). None blocks were related to complications, only 2 women referred a motility alteration on surgical side arm with spontaneous resolution.

Discussion and Conclusion: The use of such innovative techniques allows obtaining analgesia of type long-lasting, in the absence of PONV and major complications, reducing, postoperatively, the additional demand for analgesics and antiemetic. Further randomized studies are necessary to confirm our analysis.

Keywords: Regional anesthesia; PECS block; Chest wall block; Breast surgery


PONV: Postoperative Nausea and Vomiting; PECS: Pectoral Nerve Blocks; RA: Regional Anesthesia; NRS: Numerical Rating Scale; SLNB: Sentinel Lymphonode Biopsy


One of the most common surgical procedures performed in woman population is breast surgery [1]. Literature shows that 40% of women will have severe acute post-operative pain after breast cancer surgery, whereas 50% will develop chronic post-mastectomy pain with impaired quality of life [2-3]. Multimodal analgesia with poly-pharmacological approach is fundamental to prevent acute pain onset treating its chronic development. Opioids, main medications in acute postoperative setting, are a good option to control rest pain but they are less effective in the dynamic control of pain; moreover, they cause dose-related side-effects [4]. The association between acute pain and opioids could modify immunologic system efficiency; the consequence is an alteration of immune status with an angiogenis progression with a direct effect on tumour [5-7]. Moreover, Post- Operative Nausea and Vomiting (PONV) is increased by opioids consumption in the breast surgery where there is a majority of female sex, age < 50y and general anesthesia with volatile anesthetic. Regional Anesthesia (RA) techniques have provided a better acutepain control and, subsequently, less chronic pain [8]. Nowadays, thoracic epidural analgesia and thoracic paravertebral block are gold-standard for the acute pain control in breast surgery [9] but are related with possible complications and technical difficulties. Rafael Blanco described a less invasive novel technique, the Pectoral nerve block (PECS) [10-12]. This novel technique attempts to block the pectoral, intercostobrachial, intercostals II, III, IV, V, VI and long thoracic nerves.

Our multicentric study involves patients submitted at breast surgery with regional analgesia for acute pain control. We observed patients for 48h postoperative and reported acute postoperative pain. Secondary end points are the incidence of PONV, the consumption of analgesic and antiemetic drugs and the analysis of complications block related.

Materials and Methods

Study design, setting and recruitment

This is an observational, multi-center study. Study involves five Italian Hospital: Hospital “Circolo Fondazione Macchi” (Varese), Hospital of Cremona, Hospital of Lodi, Hospital “dei Colli” (Napoli) and Hospital of L’ Aquila. After the approval of our scientific and research ethic committee, and clinical trials registration (NCT02414256; Principal Investigator Andrea L Ambrosoli. April 7,2015) written informed consent was taken from 279 ASA physical status I–II-III patients, with age major of 18 years, scheduled for elective breast surgery between September 2014 and February 2015. Exclusion criteria were ASA physical status IV patients, loco-regional anesthesia contraindication, toxic abuse history, neuropatic disease, and patient’s refusal. During preoperative visit; demographic data were recorded and numerical rating score (NRS; 0–10, 0 = no pain, 10 = worst pain) was explained to patients. After informed consent, all patients were placed in the supine position and given sedation in the form of midazolam and fentanyl. Under ultrasonography guidance, patients received single shot pectoral nerve blocks with levobupivacaine 0.25% (analgesia for general anesthesia patients) or mepivacaine 2% (anesthesia in sedated awake patients). Pecs block was performed while the patient in supine position with placing the ipsilateral upper limb in abduction at 90° position with a 80mm needle (SonoTap, Pajunk, Geisingen, Germany) using a linear US probe of high frequency (6-13 MHz) after sheathing. The US probe was first placed at infraclavicular region after skin sterilization and moved laterally to locate 1st rib where pectoralis major and pectoralis minor muscles are identified at this US window. The US probe was moved toward axilla till serratus anterior muscle was identified above 2nd, 3rd and 4th ribs then the needle was inserted in plane injecting 10mL and 20mL of local anesthetic into the fascial plane between Pectoralis muscles (PECS I) and into the fascial plane between pectoralis minor muscle and serratus muscle (PECS II) respectively. Serratus plain block was performed in the same position of PECS II but underneath the serratus muscle, instead above it injecting 10mL of local anesthetic. Patients were then taken to the operating room and received general anesthesia or intravenous sedation if necessary. In the first 48 post-operative hours, every 12h, an investigator monitored and registered Numeric Rating Scale, analgesic drugs consumption, antiemetic drugs consumption and PONV.

Results and Discussion

Our multicenter observational analysis yielded 279 patients that performed breast surgery addicted with a chest wall blocks in a period of six month. Table 1 describes which type of anesthesia/sedation (inhalatory, endovenous) performed and surgical procedures characteristics. Table 2 shows the demographical data of the patients enrolled in the analysis. We have recorded the NRS values (at rest and during activity) registered at scheduled time Table 3. In Table 4 are showed the total events of PONV (defined as necessity to assume postoperative anti-emetics drugs) and complications occurred during and after chest wall blocks execution. We have only three case of strength reduction during of arm abduction in patients that received PECS II block, with a spontaneous resolution after 6 hours Table 4. In Table 5 we have noted the dose rescue of opioids intraoperative or in the immediate postoperative.