الفهرس 
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Abstract
BREAST cancer is one of the most common tumors in women worldwide. Despite advances in surgery and the increasing use of chemotherapy and endocrine therapy before surgery, mastectomy remains a common operation for breast cancer. Postoperative acute pain is a common sequel of this type of surgery and inadequate control of pain may later develop into chronic pain syndrome (paraesthesias, phantom breast pain and intercostobrachial neuralgia).
Effective pain management helps to reduce postoperative complications and leads to early mobilization and faster recovery, thereby increasing patient satisfaction and decreasing the cost of care. Analgesia can be delivered orally, intravenously, intramuscularly, or via local nerve blockade. Until now, oncologic breast surgeries are typically performed by General Anesthesia (GA). However, GA cannot provide adequate postoperative pain control and routine use of parenteral opioids aggravates postoperative sedation, nausea, vomiting, impaired oxygenation and depressed ventilation.
For these reasons, regional analgesic techniques have been advocated for effective pain management. Local wound infiltration is safe, but the duration of action is short lived. Intercostal nerve block and interpleural block are effective, but there is a risk of pneumothorax and transient Horner’s syndrome. In view of the neurological and haemodynamic concerns, thoracic epidural analgesia is not preferred for breast surgeries. Most recently, thoracic paravertebral block has been shown to provide effective analgesia with minimal haemodynamic changes. Although TPVB became the gold standard technique to achieve these goals, but not every anesthesiologist is comfortable performing these procedures.
On the other hand, attributed to the recent application of ultrasound in anesthetic practice, several interfascial plane blocks have been described recently. Serratus anterior plane block (SAPB) is a novel interfascial plane block which can provide analgesia after breast surgery with minimal side effects and easier approach to perform.
Aim of the study: this study was done to compare the analgesic efficacy of ultrasound‑guided Thoracic paravertebral block and Serratus anterior plane block in patients undergoing Mastectomy operations. This study hypothesized that the analgesic efficacy of single injection SAPB performed under US would provide a better analgesia with fewer complications in comparison with single injection TPVB.
Patients and methods: This prospective, randomized, single blind and clinical study was conducted on 60 patients underwent mastectomy. These patients were randomly allocated into two equal groups: group I: (30 patients received ultrasound guided thoracic paravertebral block with 20 ml of 0.25% Bupivacaine with epinephrine, 5μg/mL). group II: (30 patients received ultrasound guided Serratus anterior plane block with 0.4ml/kg of bupivacaine 0.25% and epinephrine 5ug/ml). Both delivered as single injection before recovery from general anesthesia.
Patients with Local skin infection at the site of injection, known allergy to one of the used drugs, diabetes mellitus with polyneuritis, renal insufficiency, coagulopathy, morbid obesity or history of chronic pain in the anterolateral region of the chest or axilla were excluded of the study.
One day before surgery all patients were interviewed to explain visual analogue scale (VAS), also routine investigations were fulfilled. Before the induction of general anaesthesia, Intravenous access (IV) was established and monitoring of the patients. Patients undergoing mastectomy surgeries (modified radical mastectomy with or without axillary clearance) were premedicated with IV midazolam and ranitidine, 60 minutes before the operation. After pre-oxygenation, general anesthesia was induced with fentanyl 1 mcg/kg and propofol 2.5 mg/kg followed by cisatracurium besylate 0.15 mg\Kg to facilitate endotracheal intubation.
End tidal CO2 was monitored with capnography. Anesthesia was maintained with isoflurane 1.2% and cisatracurium 0.03 mg/kg as a maintenance dose every 30 minutes till the end of the procedure. Heart rate was continuously monitored and MAP/ 5 minutes was maintained within ± 20% of the preoperative baseline.
Activation of regional block was done at the end of the surgical procedure then recording of parameters in the post-operative period. The ultrasound used for the block in all groups was ( GE ” LOGIQ P5” ultrasound machine ) with 6 -13 MHz probes and colour Doppler imaging capability.
In both groups, once the best image of the space was captured, under sterile conditions, an 18 gauge 8 cm epidural needle (Perifix.B.BRAUN Melsungen AG) was utilized for locating the paravertebral space and serratus anterior plane, the tip of the needle advanced under direct vision. To check for accurate positioning of the tip of the needle, hydro-dissection was done by 2-3 cc of saline after establishing negative aspiration; this was followed by local anesthetic injection of bupivacaine 0.25% plus epinephrine (5ug/ml) which visualized in real-time.
For postoperative analgesia, patients received morphine 5 mg as a rescue analgesic for breakthrough pain to achieve the visual analogue score less than 4.
The main outcome measures:- The primary targets of this current study were visual analogue scale (VAS) for pain at rest and on movement (at PACU, 4 hours, 8 hours, 12 hours, 20 hours and 24 hours postoperative) and measuring the mean morphine consumption in 24 hours .
The secondary measurements include:- Age, weight, height, ASA status, vital signs ( mean arterial blood pressure , heart rate and respiratory rate) every one hour for 6 hours postoperative , incidence of nausea and vomiting, duration of hospital stay and complications that occurred in both groups ( accidental vascular puncture, pneumothorax, nerve damage, local anesthetics toxicity ).
Results: As regard the primary target of this current study that included measuring the visual analogue scale (VAS) during rest and on movement at PACU, 4, 8, 12, 16, 20 and 24 hours postoperative and measuring 24 hours morphine consumption, Current study showed significant lower values in SAPB group compared to TPVB group as regard VAS at 12th and 16th hour postoperative during both rest and movement. Also there was increased mean morphine consumption in the first 24 hours post-operative in TPVB group compared to SAPB group.
As regard patients having postoperative nausea and vomiting, current study showed lower incidence of PONV in both groups with no significant statistical difference in between.
As regard vital signs ( mean arterial blood pressure , heart rate and respiratory rate), current study showed hemodynamic stability in both groups with no significant statistical difference in between.
As regard duration of hospital stay, current study showed no increase in the length of hospital stay in both groups with no significant statistical difference in between.
As regard block related complications, there were no complications occurred in any group.
Conclusion:- Current study recommend Serratus anterior plane block as effective technique as thoracic paravertebral block in providing postoperative analgesia in mastectomy surgery.