Regional Anesthesia for Breast surgery

乳房手術是開刀房內最常遇見的術式之一，近年來發展出各種的區域麻醉與止痛方法用以減少術後的急性疼痛與後續衍伸而出的慢性疼痛．這類術式伴隨著比想像中還嚴重的疼痛程度，沒做好疼痛控制往往會導致嗎啡類用藥增加或是術後恢復不良的狀況，且這群病人有極高比率須長期依賴嗎啡類止痛用藥．因此麻醉醫師確有必要提供更佳的術中術後止痛模式，不僅減緩急性術後疼痛，更有可能帶來長遠的好處．
胸椎脊柱旁神經阻斷術是針對乳房手術最標準的止痛方法，它可以帶來極佳的術中與術後止痛效果，有效的降低嗎啡使用量和術後噁心嘔吐的發生率．因此胸椎脊柱旁神經阻斷能讓病患有更好的術後恢復．雖然有很好的效果，但此阻斷術有較高的技術門檻與可能伴隨的嚴重併發症，因此發展出有效且較為簡單的替代方案是有必要的．
隨著超音波技術的演進，不少新型的筋膜間神經阻斷術如PECS1-2/TTP/PIFB/ESP/SPB也被拿來應用在乳房手術，不僅較為安全便利同時也提供不亞於胸椎脊柱旁神經阻斷術的成效．我們將於這堂演講呈現相關文獻與義大醫院這三年來所累積之臨床經驗分享．

Regional Anesthesia for Breast surgery

Surgeries of the breast are among the most common operative procedures, and numerous options exist for perioperative anesthesia and analgesia that can affect acute perioperative pain, persistent pain. The procedure is associated with moderate-to-severe acute postoperative pain; failure to provide adequate acute pain control is associated with increased opioid requirements, poor quality of recovery, and chronic postsurgical pain. Indeed, the risks of chronic post-surgical pain and long-term opioid dependence after breast cancer surgery are 29% and 11%, respectively. Consequently, anesthesiologists are well-positioned to provide safe and reliable perioperative interventions that optimize acute pain control and enhance long-term outcomes.

Thoracic paravertebral block has been described as the gold standard analgesic modality for breast cancer surgery. The benefits of paravertebral block have been well established, including reduced postoperative pain, decreased opioid requirements, and lower risks of postoperative nausea and vomiting. Paravertebral block also enhances quality of recovery and seems to protect against chronic postsurgical pain. However, paravertebral block is considered an invasive block requiring advanced skill and deep needling in close vicinity to the pleura, neuraxis, and intercostal neurovascular bundles such that the risks of pneumothorax, neuraxial spread, and systemic toxicity persist. These concerns seem to prompt the quest for paravertebral block alternatives.

With the advent of ultrasound, newer inter-fascial plane blocks such as PECS1-2 block / Serratus plane block / Erector spinae block (ESP) / Transversus thoracis plane (TTP) block / Pectointercostal fascial block (PIFB) have been reported for perioperative analgesia in breast surgeries. It provides much easier approach with non-inferior post-operative analgesic effect.

In this section, we will discuss the innervation of the breast tissue and new evidence of the interfascial plance block. We will also show how we cooperate with the breast surgeon to deveolop our own strategy of regional anesthesia implemented for oncological breast surgery in E-DA hospital through 2017-2020.