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Regional block safer for mastectomy, reconstruction
Regional offers lasting pain control, cuts PONV
Although mastectomies have been performed in outpatient surgery programs for several years, skepticism about the safety of outpatient mastectomies with immediate reconstruction has kept some physicians from letting patients know about the option, say experts interviewed by Same-Day Surgery.
Physician concerns about the inability to control pain as well as postoperative nausea and vomiting (PONV) have been addressed by anesthesiologists at M.D. Anderson Cancer Center in Houston. They are using a technique that not only reduces PONV but also controls pain for up to 12 hours following the surgery.
"With the paravertebral block, we use a small amount of narcotic during surgery and light sedation," explains Farzin Goravanchi, DO, anesthesiologist at M.D. Anderson. "Our patients undergo their procedure and wake within five minutes, then are able to sit and eat in another 15 minutes."
The paravertebral block provides regional pain control with injections of local anesthesia around the nerves in the region of the breast. Typically, mastectomies with immediate reconstruction require a one- to two-day stay due to the PONV that results from the use of general anesthesia and opiate narcotics during surgery and the need for continued pain control following surgery, says Goravanchi. "Some patients who receive the paravertebral block are ready to go home in as little as two hours after surgery, with the majority of patients staying for three to four hours," he says. Pain is controlled by the block for up to 12 hours so, although patients go home with a prescription for pain control medication, most patients don't use the medication or use very little of it, he adds.
Not all patients are candidates for a paravertebral block, Goravanchi says. "Patients who are morbidly obese, who have spinal deformities or have had spinal surgery, and patients who are sensitive to the anesthetic are not appropriate for the regional block," he explains.
Although the complication rate for paravertebral blocks is low, less than 0.2%, there is a risk for hypotension or pneumothorax, Goravanchi says. "This is not a procedure that can be self taught because it does have a higher risk of pneumothorax than other regional blocks," he says. "I believe that an anesthesiologist needs to train with physicians who have performed these blocks on a regular basis."
There are only a handful of medical centers that use paravertebral blocks, with M.D. Anderson and Duke Medical Center in Raleigh, NC, as the leaders in the technique, says Goravanchi. Anesthesiologists can find courses offered by these facilities, but an anesthesiologist competent in the procedure also should monitor them before they perform one alone, he points out. "Fifty blocks is considered the gold standard for determining competence," he adds.
Low complication rate
Offering mastectomies with immediate reconstruction on an outpatient basis is especially important for this particular population of patients, points out Stephanie Bernik, MD, chief of breast surgery at St. Vincent's Comprehensive Cancer Center in New York City and co-author of a study that demonstrates the safety of outpatient mastectomy with immediate reconstruction.1
"These patients are not only dealing with a surgical procedure but also with cancer and continuing treatment," she explains. "Staying in the hospital for the surgery makes the whole process even bigger and more stressful." There are criteria that patients must meet, but if they want to go home the same day of surgery, it is an option, she adds. "Patients who qualify for outpatient mastectomy and reconstruction are younger patients with no other medical problems or older patients with no major medical problems," says Bernik. "We also require that they have a strong support system or in-home nursing care at home for the immediate recovery period."
The patients are scheduled as the first patient of the day so there is time to adequately monitor them before discharge, she points out. With reconstruction, the procedure lasts about four hours, and patients need another four to five hours for recovery and monitoring, she says.
Reconstruction in the outpatient setting is the placement of tissue expanders, says Michael J. Miller, MD, a plastic surgeon at Ohio State Medical Center. "The expander is an inflatable device implanted under the muscles of the chest wall and is usually in place for up to four months," Miller says. "Saline is used to inflate the tissue expanders to simulate the breast shape," he explains. A second procedure removes the expanders and places implants to complete the reconstruction, Miller says. "I always tell my patients that reconstruction is not a single operation but a process," he adds.
Bernik says her study found few complications in outpatients and only one case that required hospitalization, which was for postoperative bleeding. "We discovered that the patient had been using a herbal supplement that increases the risk of bleeding, but she had not told us about the supplement prior to surgery," Bernik explains.
With the proven safety and the new anesthesia options, surgeons should offer outpatient mastectomy and reconstruction to patients who express a strong desire to go home immediately after surgery, she says. "The psychological benefits of being at home result in a better recovery," Bernik says. "The patient doesn't feel as sick and is better able to deal with the continuing treatment for cancer."
Patient education is critical, says Goravanchi. "You need the patient, the surgeon, the nursing staff, and the anesthesiologist to work as a team with outpatient mastectomy and reconstruction," he says. "It's important that the patient thoroughly understand the procedure and what to expect during recovery," Goravanchi says.
The successful pain control of the paravertebral block has created a need to add an extra caution to patients' postoperative instructions, he says. Because the block is so effective, patients don't experience pain or sensitivity that usually causes them to moderate activity following surgery, he says. Goravanchi explains, "The block works so well that we have to tell patients not to be too active because they have just undergone surgery."