Access to this full-text is provided by Springer Nature.
Content available from BMC Anesthesiology
This content is subject to copyright. Terms and conditions apply.
R E S E A R C H A R T I C L E Open Access
Ropivacaine infiltration analgesia of the
drainage exit site enhanced analgesic
effects after breast Cancer surgery: a
randomized controlled trial
Baona Wang
1†
, Tao Yan
1†
, Xiangyi Kong
2†
, Li Sun
3
, Hui Zheng
1*
and Guohua Zhang
1*
Abstract
Background: Postoperative pain after breast cancer surgery remains a major challenge in patient care. Local
infiltration analgesia is a standard analgesic technique used for pain relief after surgery. Its application in patients
who underwent mastectomy requires more clear elucidation. This study aimed to investigate the effect of
ropivacaine infiltration of drainage exit site in ameliorating the postoperative pain after mastectomy.
Methods: A prospective randomized controlled study was conducted in 74 patients who were scheduled for
unilateral mastectomy by standardized general anesthesia. Both intervention group and control group were given
infiltration of the two entry points of drainage catheters with 10 ml 0.5% ropivacaine (Group A) (n= 37) or 10 ml
normal saline (Group B) (n = 37). Pain scores were recorded in post-anesthesia care unit (PACU), at 6 h, 12 h, 24 h
and 36 h after operation by using a visual analogue scale (VAS). Postoperative nausea and vomiting (PONV)
incidence, postoperative analgesic and antiemetic requirements, the incidence of chronic pain, as well as the
quality of recovery were recorded.
Results: The patients in Group A showed a significant reduction in postoperative pain in PACU (p< 0.0005), at 6 h
(p< 0.0005), 12 h (p< 0.0005), and 24 h after surgery (p< 0.05) when compared to those in Group B. There were
more postoperative analgesic requirements in Group B (p< 0.05). With regard to the quality of recovery, Group A
was shown to be much superior over Group B (p< 0.05).
Conclusions: Ropivacaine infiltration of the two drainage exit sites decreased the degree of postoperative acute
pain after mastectomy, and this approach improved patients’quality of recovery.
Trial registration: retrospectively registered in Chictr.org.cn registry system on 24 February 2020 (ChiCTR2000030139).
Keywords: Local infiltration analgesia, Ropivacaine, Drainage exit site, Postoperative pain, Breast cancer
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: zhenghui0715@hotmail.com;d1974@163.com
†
Baona Wang, Tao Yan and Xiangyi Kong contributed equally to this work.
1
Department of Anesthesiology, National Cancer Center/National Clinical
Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
Full list of author information is available at the end of the article
Wang et al. BMC Anesthesiology (2020) 20:257
https://doi.org/10.1186/s12871-020-01175-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Postoperative pain is one of the most common chal-
lenges in women following breast cancer surgeries,
which impairs rehabilitation and increases the length
of hospital stay. About 50% of patients who receive
mastectomy might experience persistent postopera-
tive pain [1,2]. Sensory disturbances such as burn-
ing or sensory loss caused from the wound are
commonly observed as sequelae of mastectomy, and
thismightbeduetointraoperativenerveinjury[3].
However, complaints of acute postoperative pain in
patients who received mastectomy are also frequently
observed. After mastectomy, a drainage tube is rou-
tinely placed, which assists in monitoring bleeding,
and fluid or air removal. The wound is infiltrated or
irrigated with local anesthetic to reduce acute post-
operative pain, and is widely used in surgeries [4,5].
However, few studies have paid much attention in
investigating whether postoperative pain could be ef-
fectively alleviated by infiltrating anesthesia at the
drainage exit site after mastectomy. Based on our
clinical experiences, the major location of the acute
pain might be at the insertion sites of the two drain-
age catheters, which were placed below the skin flap
at the end of the surgical procedure. For the firm
anchorage of the drain to the skin and sealing of the
space around the drain, the two entry points of cath-
eter insertion were chosen over healthy skin below
theinframammaryfoldofthebreast,whereinmost
of the subcutaneous nerves were not damaged,
meaningthattheywerestillsensitivetopain.Park’s
study [6] reported that surgical drains are associated
with high postoperative opioid use after breast can-
cer surgery, and this supported our observation.
Although multimodal analgesic strategies including
opioids, acetaminophen, non-steroidal anti-inflammatory
drugs (NSAIDs), peripheral regional techniques, patient-
controlled modalities as well as local anesthetic tech-
niques such as wound infiltration are available, postoper-
ative pain still has been poorly managed. Analgesia-
related side-effects such as nausea and vomiting, dizzi-
ness, constipation and itching are commonly observed,
impairing patients’satisfaction and delaying their dis-
charge time [7,8]. Postoperative pain after breast cancer
surgery can be effectively alleviated by regional nerve
block techniques, for example the thoracic paravertebral
nerve block (PVB) [9]. But a long learning cycle and in-
vasive nature of the method limited the implementation
of PVB in breast cancer surgery.
This prospective randomized controlled study aimed
to investigate if infiltration of ropivacaine at the inser-
tion sites of the two drain catheters in mastectomy
would reduce postoperative acute pain, postoperative
nausea and vomiting (PONV), and chronic pain.
Methods
Study design
This prospective, randomized controlled trial was de-
signed in adherence to the CONSORT guidelines and
was registered in Chictr.org.cn registry system on 24
February 2020 (ChiCTR2000030139). This study was
conducted in Cancer Hospital, Chinese Academy of
Medical Sciences between September and November
2019, and has been approved by the institutional ethics
committee (IRB Approval Number: 20/351–2135). All
patients were followed up until 3 months after discharge
from the hospital.
Participants
Patients who underwent unilateral mastectomy with ax-
illary lymph node dissection (ALND) or sentinel lymph
node biopsy (SLNB) were enrolled in this study. Written
informed consent was obtained from patients. The pa-
tients aged 20 ~ 70 years, and with the American Society
of Anesthesiologists physical status of I to III were in-
cluded. Patients with the following conditions were ex-
cluded from the study: history of severe cardiovascular
or pulmonary, hepatic, renal, neurologic, and psychiatric
or metabolic diseases; history of allergy to any of the po-
tential study medications; active drug abuse; intake of
NSAIDs, opioids, or other analgesics in the 24 h before
surgery; pregnancy; breastfeeding, active menstruation.
Randomization
Prior to study initiation, 80 sequentially numbered enve-
lopes containing the allocation were prepared. The in-
volved patients were randomly assigned to 10 ml 0.5%
ropivacaine infiltration (Group A) or 10 ml normal saline
infiltration (Group B) groups. A physician independent
of the study randomly inserted 40 anesthesia strategies
for each group into the envelopes. The random alloca-
tion sequence was generated using computer-generated
random numbers. The researchers opened the envelope
to determine as to which anesthesia strategy to imple-
ment before the induction of general anesthesia. All
perioperative data were collected by an investigator who
was blinded to the patient’s allocation, and was respon-
sible for measuring the outcome.
Interventions
Standard general anesthesia was induced using sufenta-
nil 0.3 ~ 0.6 μg/kg, propofol 1 ~ 2 mg/kg and cis-
Atracurium 0.2 ~ 0.4 mg/kg in the two groups. After la-
ryngeal mask airway insertion, the patients were mech-
anically ventilated to maintain the end-tidal carbon
dioxide concentration at 35 ~ 45 mmHg with a fresh gas
flow of 2 L/min 60% oxygen. Anesthesia was maintained
by constant inhalation of 1.5 ~ 2.5% sevoflurane and
constant infusion of remifentanil at a rate of 0.1 ~
Wang et al. BMC Anesthesiology (2020) 20:257 Page 2 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
0.2 μg/kg/min. Sufentanil 0.1 μg/kg was added intraoper-
atively as required. At the end of the surgery all patients
received 100 mg of flurbiprofen (an NSAID). Dexa-
methasone 8 mg (given after induction) and ondansetron
4 mg (given at the end of surgery) were used for preven-
tion of postoperative nausea and vomiting (PONV). All
surgical procedures were finished by the same surgical
team with the same standardized technique. The two
drainage catheters were placed by the surgeon before
closing the surgical incision. Before the placement, the
subcutaneous tissue of the two entry points of the cathe-
ters received local infiltration, which included interven-
tion group (Group A) by 10 ml 0.5% ropivacaine and
control group (Group B) by 10 ml normal saline (5 ml
for each point). After operation, all patients were extu-
bated and transferred to the post-anesthesia care unit
(PACU). Flurbiprofen 100 mg was provided by intraven-
ous injection daily to control the postoperative pain
within 3 days after operation. If the pain visual analogue
scale (VAS) was ≥3, 100 mg tramadol was administered
as a rescue analgesic. For postoperative antiemetic treat-
ment, metoclopramide was intravenously administrated
if the nausea VAS was ≥5 or episodes of vomiting ≥2.
All patients received standard postoperative therapies
according to the pathological characteristics.
Outcomes
The primary outcomes
The pain was immediately assessed after returning to
PACU and at 6 h, 12 h, 24 h, and 36 h after operation
using a VAS (0 = no pain to 10 = most severe pain). The
incidence of PONV was recorded simultaneously, using
a three-point ordinal scale (0 = none, 1 = nausea, 2 =
retching, 3 = vomiting), and nausea was evaluated by
VAS. The number of patients who received postopera-
tive analgesic or antiemetic drugs was recorded.
Secondary outcomes
The status of chronic pain in patients was collected
using the breast cancer pain questionnaire, which was
first developed by Gartner et al. [3]. A Pain Burden
Index (PBI) can be calculated according to the data col-
lected by the questionnaire surveys. It was calculated by
adding the pain severity scale (0 ~ 10) from anatomic lo-
cations of breast, axilla, chest wall and arm, and multi-
plied by the frequency of pain at each site (constantly—5
points, daily—4 points, occasionally—3 points, weekly—
2 points, monthly—1 point, and never—0 points).
The quality of recovery including 40 questions (QoR-
40), which is used as a measure of quality of recovery,
was distributed to patients for collecting data 24 h after
operation. This included five factors of emotional state,
physical comfort, psychological support, physical inde-
pendence, and pain. In all, the highest score was 200
while the lowest being 40 and the more score, the better
the results.
Also the remaining data, including the consumption of
sufentanil during the surgery, types of surgical proce-
dures, operation and anesthesia time, age, body mass
index (BMI), history of smoking and PONV were
collected,
Sample size and statistical analysis
The sample size was calculated based on our preliminary
experiment that enrolled 10 cases in each group. The
mean pain VAS at 12 h after the surgery was 1.2 ± 2.1
for Group A and 2.9 ± 2.2 for Group B. Using standard
sample size calculation formula to achieve a power of
0.8 at α= 0.05, there should be at least 29 patients in-
cluded in each group to detect a significant difference.
Considering the possibility of data censored, a total of
40 patients in each group were recruited to guarantee
the sample size. SPSS 23.0 for windows (SPSS, Inc., Chi-
cago, IL, USA) was used for data analysis. Normally dis-
tributed continuous data were expressed as means (SD),
and were analyzed using analysis of variance (ANOVA),
independent-sample t-test or paired t-test. Nonparamet-
ric data were analyzed by Mann-Whitney and Wilcoxon
text. Two-sided tests were performed to declare statis-
tical significance at p< 0.05.
Results
The random assignment of the participants into the two
groups and analysis of the outcome was presented in
Fig. 1. Finally, a total of 74 patients were included in this
study. Demographic characteristics, including age, body
weight, body height, BMI, smoking status, and history of
PONV were comparable in both groups (Table 1). In
addition, no significant differences were found in the
consumption of sufentanil during surgery, the durations
of anesthesia and surgery, and the types of surgical pro-
cedures used (Table 1).
Surgical drains were reported to be associated with
high postoperative opioid use after breast-conserving
surgery
6
. Although whether surgical drains increase opi-
oid consumption after mastectomy has not been investi-
gated, pain originating from the insertion sites of the
two drainage catheters constitutes a major part of acute
postoperative pain. In this study, we found that ropiva-
caine infiltration of the two drainage exit sites have sig-
nificantly reduced the postoperative pain in PACU (VAS
score, 0.54 ± 1.07 vs. 1.97 ± 1.48, p< 0.0005), at 6 h (VAS
score, 0.49 ± 1.12 vs. 2.24 ± 1.36, p< 0.0005), 12 h (VAS
score, 0.86 ± 1.29 vs. 2.30 ± 1.35, p< 0.0005), and 24 h
after operation (VAS score, 1.35 ± 1.27 vs. 1.97 ± 1.32,
p< 0.05) (Fig. 2). However, at 36 h after operation, a sig-
nificant difference was not observed any more (1.51 ±
1.15 vs. 1.68 ± 1.23, p> 0.05) (Fig. 2). More number of
Wang et al. BMC Anesthesiology (2020) 20:257 Page 3 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
patients required for postoperative rescue analgesic in
Group B than in Group A (17 vs. 7, p< 0.05).
We did not collect pain scores of restricted movement of
the shoulder and values of arm abduction angle. Because
the operated arm was tightly bound and forbidden to move
by surgeons within 3 days after the operations, in case of
wound dehiscence, subcutaneous effusion and hematoma.
The intervention showed no effect on the incidence of
chronic pain within 3 months, and PBI in the two
groups showed similar results (Table 2). No significant
differences were found between the two groups in terms
of PONV incidence (Table 3) and the requirements for
postoperative antiemetic treatment. The QoR-40 score
of Group A was significantly higher than Group B
(185.8 ± 8.3 vs 179.7 ± 11.2, p< 0.05).
Discussion
To our knowledge, this is the first prospective random-
ized controlled study to reveal ropivacaine infiltration of
Fig. 1 Flow of patients throughout study
Table 1 Baseline characteristics of patients in the study and the control groups
Group A(n= 37) Group B(n= 37) Pvalue
Age (years)
a
52.1 ± 9.0 49.1 ± 9.9 0.17
Weight (kg)
a
61.8 ± 8.7 59.8 ± 8.4 0.32
Height (cm)
a
160.3 ± 5.5 159.4 ± 5.0 0.44
Body mass index
a
24.0 ± 3.6 23.9 ± 3.1 0.82
Smoking (%) 00–
History of PONV (%) 5 (13.5%) 4 (10.8%) 0.48
Surgical procedure 0.41
mastectomy + axillary dissection (%) 30 (80.1%) 27 (73.0%)
mastectomy + SNLB (%) 7 (19.9%) 10 (27.0%)
Surgery time (min)
a
98.1 ± 31.3 111.0 ± 28.8 0.07
Length of anesthesia (min)
a
113.5 ± 30.1 125.5 ± 27.9 0.08
Consumption of Sufentanil (μg)
a
24.8 ± 5.7 23.8 ± 5.0 0.42
a
Values are expressed as the mean ± standard deviation; PONV postoperative nausea and vomiting; SNLB sentinel lymph node biopsy
Wang et al. BMC Anesthesiology (2020) 20:257 Page 4 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
the two drainage exit sites, which significantly reduced
postoperative pain and analgesic requirements and im-
proved the quality of recovery after mastectomy.
Park’s study [10] reported that compared with other
breast surgical procedure types, mastectomy required
consumption of more opioids during the first week post-
operatively. Opioid consumption plays an important role
in postoperative pain control after mastectomy. How-
ever, opioid-related adverse effects led to other problems
that delay the recovery, and so novel analgesics or strat-
egies with less side-effects are urgently needed. Kaira-
luoma et al. [11] have found that PVB could improve
postoperative pain and reduce opioid consumption after
modified radical mastectomy. Nevertheless, compared
with local infiltration anesthesia, the regional block tech-
nique is considered more challenging technically, and
needs a longer learning period. According to our results,
ropivacaine infiltration of the two drainage exit sites
during mastectomy is a simple, easy, and economical ap-
proach for pain relieving, without any opioid-related ad-
verse effects. Correspondingly, postoperative analgesic
requirements were reduced, and the quality of recovery
was improved.
To compare with the previous similar studies, in
Table 4we summarized 8 randomized controlled trials
that evaluated the efficacy of local analgesic for pain re-
lief in breast cancer surgery, in which the local analgesic
was either injected into the wound preoperatively or in-
stilled through the drainage tube into the wound postop-
eratively. However, in this study, we chose to perform
local infiltration anesthesia of the two drainage exit sites
with ropivacaine, based on the evidence that pain caused
by the drainage plays a vital role in postoperative pain.
Five of the above mentioned trials [12–16] showed no
differences between the control and experimental
groups, in which Baudry et al.’s studies [12] enrolled pa-
tients who received breast-conserving surgery with or
without ALND. However, the postoperative pain of dif-
ferent types of surgical technique remained different.
The breast-conserving surgeries are susceptible to acute
pain of the wound. In contrast, mastectomy surgeries
are susceptible to burning, sensory loss or other abnor-
mal sensations due to nerve damage, while acute pain is
not reported as the main complaint [20]. Thus, it is not
precise to compare the pain score between these two
types of surgery due to the different mechanisms of pain.
Our study is designed by including patients who re-
ceived mastectomy, which provided comparable results.
Nirmala et al. [17–19] have found that the local anal-
gesic group showed significant reduction in the postop-
erative pain within 90 min, 6 h, and 15 h, respectively.
Although the infiltration location in our study was dif-
ferent from theirs, local infiltration anesthesia showed
effective results for patients who received mastectomy,
and had a longer effective duration (24 h).
Fig. 2 Pain VAS score of patients in the study and control groups.
Compared with Group B, postoperative pain in Group A was
significantly reduced in PACU (VAS score, 0.54 ± 1.07 vs. 1.97 ± 1.48,
p< 0.0005), at 6 h (VAS score, 0.49 ± 1.12 vs. 2.24 ± 1.36, p< 0.0005),
12 h (VAS score, 0.86 ± 1.29 vs. 2.30 ± 1.35, p< 0.0005), and 24 h after
operation (VAS score, 1.35 ± 1.27 vs. 1.97 ± 1.32, p< 0.05). *p< 0.05;
Group A: intervention group (ropivacaine infiltration); Group B:
control group (normal saline infiltration); PACU: Post-anesthesia care
unit; VAS: Visual analogue scale
Table 2 Incidence of chronic pain in the study and the control
groups
Group A (n= 37) Group B (n= 37) pvalue
Location
Chest wall 8 (21.6%) 12 (32.4%) 0.30
Axillary 9 (24.3%) 7 (18.9%) 0.58
arm 5 (13.5%) 4 (10.8%) 0.72
Total 19 (51.4%) 16 (43.2%) 0.49
PBI
a
7.3 ± 9.7 7.3 ± 9.0 0.75
a
Values are expressed as the mean ± standard deviation; PBI Pain Burden Index
Table 3 Incidence of PONV in the study and the control groups
Group A (n= 37) Group B (n= 37) pvalue
In the PACU
PONV 9 (24.3%) 11 (29.7%) 0.93
Asymptomic 28 (75.7%) 26 (70.3%)
PACU-6 h
PONV 8 (21.6%) 8 (21.6%) 0.90
Asymptomic 29 (78.4%) 29 (78.4%)
6h–12 h
PONV 6 (16.2%) 12 (32.4%) 0.12
Asymptomic 31 (83.8%) 25 (67.6%)
12 h–24 h
PONV 3 (8.1%) 5 (13.5%) 0.46
Asymptomic 34 (91.9%) 32 (86.5%)
24 h–36 h
PONV 0 (0%) 1 (2.7%) 0.31
Asymptomic 37 (100%) 36 (97.3%)
PONV postoperative nausea and vomiting; PACU post-anesthesia care unit
Wang et al. BMC Anesthesiology (2020) 20:257 Page 5 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
The incidence of PONV in the two groups remained
similar. However, from 6 h to 12 h after operation,
PONV occurred in 6 patients in Group A and 12 in
Group B. This difference might due to the side-effects of
higher tramadol requirement in Group B. At 3-months
follow-up, no significant differences were discovered
with regard to the incidence of chronic pain. The mech-
anism of chronic pain is complicated, and it is still
poorly controlled. Although our intervention decreased
the postoperative pain more effectively, no surgical,
demographic, and psychosocial factors that influenced
chronic pain after breast surgery considered [21]. It has
been reported that 30% ~ 51% of patients suffered from
persistent pain after breast cancer surgery [2]. In our
study, 51.35% of patients in Group A and 43.24% in
Group B suffered from chronic pain. Nearly half of the
patients are tortured by chronic pain. Therefore, it is still
regarded as a great challenge to explore the reduction
and treatment of chronic pain after breast cancer sur-
gery. Furthermore, combined with the other pain-
control methods, local infiltration anesthesia might fur-
ther reduce the occurrence of postoperative acute pain,
and even have positive effects on chronic pain.
However, there are certain limitations in this study
that require consideration. Firstly, the sample size is
small, and so it is not sufficient to perform subgroup
analysis. Secondly, follow-up of the patient’s pain after
3-months was not evaluated.
Conclusions
In conclusion, ropivacaine infiltration of two drainage
exit sites effectively decreased the degree of postopera-
tive acute pain and analgesic requirements within 24 h,
and meanwhile improved patients’quality of recovery.
Further large scale studies are warranted to study the
outcomes in the future, and explore efficient approach
that relieve pain after mastectomy in long run.
Abbreviations
PACU: Post-anesthesia care unit; PONV: Postoperative nausea and vomiting;
VAS: Visual analogue scale; NSAIDs: Nonsteroidal anti-inflammatory drugs;
BMI: Body mass index; SD: Standard deviation; ANOVA: Analysis of variance;
PBI: Pain burden index; PVB: Paravertebral nerve block; ALND: Axillary lymph
node dissection; SLNB: Sentinel lymph node biopsy
Acknowledgements
We thank our colleagues at the Department of Anesthesiology, National
Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital,
Chinese Academy of Medical Sciences and Peking Union Medical College,
Beijing, 100021, China.
Authors’contributions
WBN contributed to study design, data collection and analysis, drafting of
manuscript. GHZ and ZH contributed to study design, data collection and
analysis, drafting of manuscript. YT and KXY contributed to the study design,
data analysis and interpretation, and revised the manuscript. SL contributed
Table 4 Characteristics of the selected randomized controlled trials
Study Research aim Surgical technique Intervention Infiltration locations Result Ref
Baudry
[2008]
evaluate the effect of
R wound infiltration
MRM or partial
mastectomy with ALND
R: 4.75 mg/mL R
40 mL
C: NS 40 mL
The wound no differences [12]
Johansson
[2003]
whether infiltration
with R + fentanyl
improves PP
Partial mastectomy with
or without ALND
R1: 0.375% R
R2: 0.375% R +
Fentanyl 0.5 μg/kg
C: Nil
The wound no differences [13]
Johansson
[2000]
whether infiltration
with R improves PP
Partial mastectomy with
or without ALND
R: R 3.75 mg/mL
C: NS 0.3 mL/kg
The wound of breast and axilla no differences [14]
Rica [2007] if infiltration with R
could improve PP
Mastectomy and ALND R1: Preoperative
0.2% R 20 mL + NS
to 80 mL
R2: Postoperative
0.2% R 20 mL + NS
to 80 mL
The wound no differences [15]
Talbot
[2004]
determine the
influence of B
irrigation on PP
MRM B: 0.5% B 20 mL
C: NS
Through the axillary drain into the
axillary wound
no differences [16]
Nirmala
[2019]
Whether wound
instillation with B
improve PP
MRM R: 0.25% B 40 ml
C: 40 ml normal
saline
through chest and axillary drains into
the wound
providing better
analgesia within
15 h
[17]
Vigneau
[2011]
document the effect
of R infiltration
Mastectomy or
lumpectomy with ALND
R: R 7.5 mg/mL
solution 20 mL
C: NS 20 mL
The wound PP was lower at
2, 4 and 6 h after
surgery
[18]
Albi-
Feldzer
[2013]
evaluate the
influence of R
wound infiltration
Conservative surgery with
ALND, MRM with or
without ALND
R: 0.375% R 3 mg/
kg mixed with
saline
C: Saline solution
the wound, the 2nd & 3rd intercostal
spaces and the humeral insertion of
major pectoralis
decreased
immediate PP
(≤90 min)
[19]
ALND axillary lymph node dissection; Bbupivacaine; Ccontrol; MRM modified radical mastectomy; NS normal saline; Rropivacaine; PP postoperative pain
Wang et al. BMC Anesthesiology (2020) 20:257 Page 6 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
to data analysis, and revised the manuscript. All authors have read and
approved the final manuscript.
Funding
This study was funded by Beijing Hope Run Special Fund of Cancer
Foundation of China (LC2019B11), and Sanming Project of Medicine in
Shenzhen, Cancer Pain Treatment and Perioperative Medical Team of
Professor Li Sun in Cancer Hospital, Chinese Academy of Medical Sciences.
The funders had no role in study design, data collection and analysis,
preparation of the manuscript, or decision to publish.
Availability of data and materials
All the data used and analyzed are available from corresponding authors
upon the reasonable request.
Ethics approval and consent to participate
This study was approved by the ethics committee of National Cancer
Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking
Union Medical College (IRB Approval Number: 20/351–2135). Written
informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Anesthesiology, National Cancer Center/National Clinical
Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China.
2
Department of Breast Surgery, National Cancer Center/National Clinical
Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China.
3
Department of Anesthesiology, National Cancer Center/National Clinical
Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Shenzhen
518116, China.
Received: 13 May 2020 Accepted: 24 September 2020
References
1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience:
results from a National Survey Suggest Postoperative Pain Continues to be
undermanaged. Anesth Analg. 2003;97:534–40.
2. Wang L, Gordon GH, Sean SA, Romerosa B, Kwon HY, Kaushal A, et al.
Predictors of persistent pain after breast cancer surgery: a systematic review
and meta-analysis of observational studies. CMAJ. 2016;188:352–61.
3. Gartner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence
of and factors associated with persistent pain following breast cancer
surgery. JAMA. 2009;302:1985–92.
4. Nadeem M, Sahu A. Ultrasound guided surgery under Dilutional local
anesthesia and no sedation in breast cancer patients. Surgeon. 2020;18:91–
4.
5. Rao KV, Ludbrook G, van Wijk RM, Hewett PJ, Moran JL, Thiruvenkatarajan V,
et al. Comparison of ultrasound-guided transmuscular quadratus lumborum
block catheter technique with surgical pre-peritoneal catheter for
postoperative analgesia in abdominal surgery: a randomised controlled trial.
Aneasthesia. 2019;74:1381–8.
6. Park KU, Kyrish K, Yi M, Bedrosian I, Caudle AS, Kuerer HM, et al. Opioid use
after breast-conserving surgery: prospective evaluation of risk factors for
high opioid use. Ann Surg Oncol. 2020;27:730–5.
7. Del Vecchio G, Spahn V, Stein C. Novel opioid analgesics and side effects.
ACS Chem Neurosci. 2017;8:1638–40.
8. Duthie DJ, Nimmo WS. Adverse effects of opioid analgesic drugs. Br J
Anaesth. 1987;59:61–77.
9. Naja ZM, Naccache N, Ziade F, El-Rajab M, Itani T, Baraka A. Multilevel nerve
stimulator-guided paravertebral block as a sole anesthetic technique for
breast cancer surgery in morbidly obese patients. J Anesth. 2011;25:760–4.
10. Park KU, Kyrish K, Terrell J, Yi M, Caudle AS, Hunt KK, et al. Surgeon
perception versus reality: opioid use after breast cancer surgery. Surg Oncol.
2019;119:909–15.
11. Kairaluoma PM, Bachmann MS, Korpinen AK, Rosenberg PH, Pere PJ. Single-
injection paravertebral block before general anesthesia enhances analgesia
after breast cancer surgery with and without associated lymph node biopsy.
Anesth Analg. 2004;99:1837–43.
12. Baudry G, Steghens A, Laplaza D, Koeberle P, Bachour K, Bettinger G, et al.
Ropivacaine infiltration during breast cancer surgery: postoperative acute
and chronic pain effect. Ann Fr Anesth Reanim. 2008;27:979–86.
13. Johansson A, Kornfält J, Nordin L, Svensson L, Ingvar C, Lundberg J. Wound
infiltration with ropivacaine and fentanyl: effects on postoperative pain and
PONV after breast surgery. J Clin Anesth. 2003;15:113–8.
14. Johansson A, Axelson J, Ingvar C, Luttropp H-H, Lundberg J. Preoperative
ropivacaine infiltration in breast surgery. Acta Anaesthesiology Scand. 2000;
44:1093–8.
15. Rica MA, Norlia A, Rohaizak M, Naqiyah I. Preemptive ropivacaine local
anesthetic infiltration versus postoperative ropivacaine wound infiltration in
mastectomy: postoperative pain and drain outputs. Asian J Surg. 2007;30:
34–9.
16. Talbot H, Hutchinson SP, Edbrooke DL, Wrench I, Kohlhardt SR. Evaluation of
a local anaesthesia regimen following mastectomy. Anesthesia. 2004;59:
664–7.
17. Nirmala J, Harsh K, Padmaja D, Gopinath R. Role of wound instillation with
bupivacaine through surgical drains for postoperative analgesia in modified
radical mastectomy. Indian J Anesthesia. 2015;59:15–20.
18. Vigneau A, Salengro A, Berger J, Rouzier R, Barranger E, Marret E, et al. A
double blind randomized trial of wound infiltration with ropivacaine after
breast cancer surgery with axillary nodes dissection. BMC Anesthesiol. 2011;
11:23.
19. Albi-Feldzer A, Mouret-Fourme EE, Hamouda S, Motamed C, Dubois PY,
Jouanneau L, et al. A double-blind randomized trial of wound and
intercostal space infiltration with ropivacaine during breast cancer surgery:
effects on chronic postoperative pain. Anesthesiology. 2013;118:318–26.
20. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and
prevention. Lancet. 2006;367:1618–25.
21. Tara L, Emily D, Nantthasorn Z, Tari A, Laura D, Rob R, et al. Chronic pain
after breast surgery: a prospective, observational study. Ann Surg Oncol.
2018;25:2917–24.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Wang et al. BMC Anesthesiology (2020) 20:257 Page 7 of 7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
