Eur J Anaesthesiol 2018; 35:215–223

ORIGINAL ARTICLE

Impact of pectoral nerve block on postoperative pain

and quality of recovery in patients undergoing breast
cancer surgery
A randomised controlled trial
Downloaded from https://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3tjcLwhL8g9bZhhig7WeJvo6RTrjIcQkAR5QEDwxoYKrkMig0E1/nsQ== on 09/10/2019

Yoshinori Kamiya, Miki Hasegawa, Takayuki Yoshida, Misako Takamatsu and Yu Koyama

BACKGROUND In recent years, thoracic wall nerve blocks,
such as the pectoral nerve (PECS) block and the serratus
plane block have become popular for peri-operative pain
control in patients undergoing breast cancer surgery. The
effect of PECS block on quality of recovery (QoR) after
breast cancer surgery has not been evaluated.
OBJECTIVES To evaluate the ability of PECS block to
decrease postoperative pain and anaesthesia and analgesia
requirements and to improve postoperative QoR in patients
undergoing breast cancer surgery.
DESIGN Randomised controlled study.
SETTING A tertiary hospital.
PATIENTS Sixty women undergoing breast cancer surgery
between April 2014 and February 2015.
INTERVENTIONS The patients were randomised to receive
a PECS block consisting of 30 ml of levobupivacaine 0.25%
after induction of anaesthesia (PECS group) or a saline mock
block (control group). The patients answered a 40-item QoR
questionnaire (QoR-40) before and 1 day after breast cancer
surgery.
MAIN OUTCOME MEASURES Numeric Rating Scale score
for postoperative pain, requirement for intra-operative propofol
and remifentanil, and QoR-40 score on postoperative day 1.
RESULTS PECS block combined with propofol–remifentanil
anaesthesia significantly improved the median [interquartile
range] pain score at 6 h postoperatively (PECS group 1 [0 to
2] vs. Control group 1 [0.25 to 2.75]; P ¼ 0.018]. PECS block
also reduced propofol mean ( SD) estimated target blood
concentration to maintain bispectral index (BIS) between 40
and 50 (PECS group 2.65 ( 0.52) vs. Control group 3.08 (
0.41) mg ml1; P < 0.001) but not remifentanil consumption
(PECS group 10.5 ( 4.28) vs. Control group 10.4 (
4.68) mg kg1 h1; P ¼ 0.95). PECS block did not improve
the QoR-40 score on postoperative day 1 (PECS group 182
[176 to 189] vs. Control group 174.5 [157.75 to 175]).
CONCLUSION In patients undergoing breast cancer sur-
gery, PECS block combined with general anaesthesia
reduced the requirement for propofol but not that for remi-
fentanil, due to the inability of the PECS block to reach the
internal mammary area. Further, PECS block improved post-
operative pain but not the postoperative QoR-40 score due
to the factors that cannot be measured by analgesia imme-
diately after surgery, such as rebound pain.
TRIAL REGISTRATION This trial is registered with the
University Hospital Medical Information Network Clinical
Trials Registry (UMIN000013435).
Published online 8 December 2017

Introduction
Despite the recent shift towards less invasive procedures, surgery. Regional anaesthesia techniques with or without
breast cancer surgery is still associated with moderate to general anaesthesia have been reported to provide better
severe postoperative pain that can impede recovery after acute pain control.1–5 Thoracic paravertebral block

From the Division of Anesthesiology (YK, TY, MT), Division of Digestive and General Surgery (MH), Department of Anesthesiology, Uonuma Institute of Community
Medicine, Niigata University Medical and Dental Hospital (YK), Department of Breast Surgery, Niigata Cancer Center Hospital, Niigata (MH), Department of Anesthesiology,
Kansai Medical University Hospital, Osaka (TY) and Department of Nursing, Niigata University Graduate School of Health Sciences, Niigata, Japan (YK)
Correspondence to Yoshinori Kamiya, MD, PhD, Division of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-dori, Chuo ward, Niigata,
Niigata 951-8510, Japan Tel: +81 25 227 2328; fax: +81 25 227 0790; e-mail: y-kamiya@med.niigata-u.ac.jp

0265-0215 Copyright ß 2018 European Society of Anaesthesiology. All rights reserved. DOI:10.1097/EJA.0000000000000762

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 216 Kamiya et al.

(TPVB) combined with general anaesthesia has been
shown to improve quality of recovery (QoR), a patient-
oriented outcome measure evaluated using a multidi-
mensional QoR assessment tool.1,6–9 However, TPVB
has the potential risks of pneumothorax and spread of
local anaesthetic into the spinal canal, even under ultra-
sound guidance.10,11 In recent years, thoracic wall nerve
blocks, such as the pectoral nerve (PECS) block12,13 and
the serratus plane block,14 have become popular for peri-
operative pain control in patients undergoing breast
cancer surgery.15–18 Earlier clinical trials have shown that
a PECS block combined with general anaesthesia
achieves superior outcomes with regard to postoperative
pain control, duration of hospital stay and incidence of
postoperative nausea and vomiting (PONV) when com-
pared with general anaesthesia only16 or TPVB with
general anaesthesia.17 However, the effect of PECS
block on QoR in patients undergoing breast cancer sur-
gery has still not been elucidated.
We hypothesised that the PECS block would not only
reduce pain during and after breast cancer surgery but
also improve QoR. We conducted this prospective, ran-
domised, placebo-controlled, double-blind study to
examine this hypothesis. We also compared the postop-
erative food intake between the two groups because food
intake may reflect not only the severity of PONV but
also QoR.
Methods
Design and patients
The current clinical trial was approved by the institu-
tional review board at Niigata University Medical and
Dental Hospital (accession number 1856; date of
approval by the ethics committee 5 March 2014) and is
registered at the University Hospital Medical Informa-
tion Network Clinical Trials Registry [UMIN000013435
(http://www.umin.ac.jp/ctr/index.htm)]. After obtaining
written informed patient consent, we enrolled women
aged 20 to 80 years with American Society of Anesthe-
siologists physical status I to II who were scheduled for
unilateral breast tumour resection. The surgical proce-
dures included partial mastectomy, partial mastectomy
with sentinel lymph node biopsy, simple mastectomy,
mastectomy with sentinel lymph node biopsy and mas-
tectomy with axillary lymph node dissection. The exclu-
sion criteria included the following: refusal to participate,
inability to understand Japanese, history of allergy to the
study medication, contraindications to regional anaesthe-
sia (including coagulopathy and infection at the injection
site), BMI more than 30 kg m2, body weight less than
40 kg, hepatic and/or renal failure, pre-existing abnormal
sensation affecting the thoracic trunk and history of
treatment for chronic pain and/or a psychiatric disorder.
Patients were randomly allocated to a PECS group that
received a PECS block and general anaesthesia or a
control group that received a mock block with normal
saline and general anaesthesia. An investigator not
involved in patient care or postoperative assessment per-
formed the randomisation using a computer-generated
randomisation sequence (http://www.randomization.com)
that was concealed using sealed prenumbered opaque
envelopes.
Anaesthetic procedure
The patients were not premedicated before surgery, but
all received 8 mg of intravenous dexamethasone sodium
phosphate before induction of anaesthesia as prophylaxis
for nausea. General anaesthesia was induced by a target-
controlled infusion of propofol (target blood concentra-
tion 4.0 mg ml1), a continuous infusion of remifentanil
(0.5 mg kg1 min1) and a bolus injection of rocuronium
0.6 mg kg1 to facilitate insertion of the ProSeal Laryn-
geal Mask Airway (PLMA; Teleflex Medical Japan,
Tokyo, Japan). Anaesthesia was maintained by target-
controlled infusion of propofol, and the target site con-
centration was adjusted so that the value of BIS was
within the range of 40 to 50 before starting surgery. The
rate of remifentanil infusion was adjusted in the range of
0.05 to 0.5 mg kg1 min1 and the heart rate and blood
pressure were maintained within 20% of the baseline
values. Muscle relaxation was maintained by intermittent
boluses of rocuronium as needed. After general anaes-
thesia was established, a PECS block was performed
using 0.25% levobupivacaine (PECS group) or normal
saline (control group) with S-Nerve ultrasound apparatus
(SonoSite Inc, Bothell, Washington, USA) and a 6 to 13-
MHz linear transducer (HFL 38; SonoSite Inc) as
described elsewhere.13 Briefly, the transducer was placed
on the outer third of the clavicle and then moved laterally
to identify the pectoralis major and minor muscles just
above the second rib under sterile conditions. The needle
(22-G, 80-mm Uniever for epidural anaesthesia; Unisis
Corp., Tokyo, Japan) was inserted in plane with the
transducer into the fascial plane between the pectoralis
muscles and 10 ml of levobupivacaine 0.25% was
injected. The transducer was then moved towards the
axilla until the serratus anterior muscle was identified
above the third and fourth ribs; the needle was then
reinserted until the tip of the needle was in contact with
the surface of the fourth rib. Then, 20 ml of 0.25%
levobupivacaine was injected beneath the serratus ante-
rior muscle at the fourth rib in increments of 5 ml after
confirming negative aspiration. Anaesthetists blinded to
study group allocation performed the block procedure.
After resection of the tumour and axillary clearance (if
applicable), 1 g of acetaminophen and 100 mg of tramadol
hydrochloride were administered intravenously for tran-
sitional analgesia. After completion of surgery, propofol
and remifentanil were discontinued and 4 mg kg1 of
sugammadex was administered for reversal of neuromus-
cular blockade. After confirming that the patient
responded promptly to a verbal command, the PLMA

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 Pectoral nerve block and recovery from breast cancer surgery 217

mask was removed. The patients were returned to a ward PECS block on QoR after surgery. We also evaluated the
after 20 min of observation in the operating theatre. relationship between QoR score and patient age.
After surgery, a 25-mg diclofenac sodium suppository and
15 mg of intramuscular pentazocine were provided as Statistical analysis
first-line and second-line rescue analgesics, respectively, Our sample size calculation was based on the assumption
for breakthrough pain. After starting oral intake of food, that the difference in NRS scores for pain at 6 h after
loxoprofen 60 mg and acetaminophen 500 mg were pro- surgery would be significant if there was at least one point
vided when the Numeric Rating Scale (NRS) score of difference between patients who received a PECS
(0 ¼ no pain, 10 ¼ worst pain) for postoperative pain block before breast cancer surgery and those who
was more than 4 or additional analgesics were required. received a mock block, as in a previous study.16 According
Intravenous opioids were not used during the postopera- to our preliminary study, the variability (SD) of NRS
tive period in this study to minimise the risk of PONV, scores for pain at 6 h after breast cancer surgery was 1.25.
which was treated with intravenous metoclopramide Thus, a power analysis using a type I error estimate of 5%
10 mg as needed. Patients were permitted to drink water and a power of 80% indicated that a sample size of 25
4 h after surgery and to eat food on postoperative day patients per group was needed to detect this difference.
(POD) 1. Considering dropout, we planned to enrol 60 patients.
The Shapiro–Wilk test was used to check the normality
Measurement
of the data. Categorical data (presented as frequencies)
The ward nursing staff, blinded to each patient’s treat-
were compared using Fisher’s exact test. Ordinal data and
ment allocation, recorded postoperative pain at rest at 1,
nonnormally distributed continuous data (presented as
3, 6, 24 and 48 h after surgery using the NRS and recorded
the median and interquartile range) were compared
the presence of PONV at any time after surgery. The
between the groups using the Mann–Whitney U test.
nursing staff also recorded the amount of food intake at
Normally distributed data (presented as the mean and
breakfast, lunch and supper (0, 25, 33, 50, 66, 75, 80 and
SD) were compared between the groups using the two
100% of the total quantity served). Patients could be
sample-independent t tests. For evaluation of postopera-
discharged 24 h after surgery if they met all the discharge
tive NRS scores and percentage of food intake, we used
criteria (no drainage from the surgical site, no active
the Mann–Whitney U test for pairwise comparisons at
bleeding, no intractable pain that could not be controlled
each time point. We also used Pearson’s test to evaluate
by the oral medication described above and absence of
the relationship between several parameters and
PONV).
QoR scores.
The quality of postoperative functional recovery was
A power analysis was performed using Gpower version
assessed using the Japanese version of the 40-item
3.1.9 for Macintosh and other statistical analyses were
QoR questionnaire (QoR-40), which assesses five dimen-
performed using Microsoft Excel 2011 for Macintosh
sions of recovery, comprising physical comfort (12 items),
(Microsoft, Redmond, Washington, USA) with a statisti-
emotional state (nine items), physical independence (five
cal macro (XLSTAT version 2013.6.01; Addinsoft, New
items), psychological support (seven items) and pain
York, New York, USA). A P value less than 0.05 was
(seven items).19 Each item is rated on a five-point Likert
considered to be statistically significant.
scale, that is none of the time, some of the time, usually,
most of the time, and all of the time. The total score on
Results
the QoR-40 ranges from 40 (poorest QoR) to 200 (best
Basic information
QoR). The QoR-40 was administered on the day before
We assessed 79 patients for eligibility to participate in the
surgery, POD 1 (between 6 and 9 p.m.), and 1 month after
study. Ten patients did not meet the inclusion criteria,
surgery. At the 1-month assessment, the patients
nine declined enrolment and the remaining 60 patients
answered the QoR questionnaire before receiving an
consented to participate. Thirty patients were allocated
explanation of their condition at the outpatient breast
to the PECS group and 30 to the control group. One
surgery clinic.
patient in the PECS group was excluded because of an
incomplete QoR questionnaire, leaving 29 patients in the
Outcomes
PECS group and 30 in the control group for analysis. At
The primary outcome was the severity of postoperative
the time of the QoR survey 1 month after surgery, five
pain on the NRS at 6 h after surgery. The secondary
and nine patients in the PECS group and control group,
outcomes were differences in doses of propofol and
respectively, were excluded from the analysis because of
remifentanil, QoR-40 score on POD 1 between the
an incomplete QoR questionnaire or loss to follow-up
two groups, the incidence and severity of PONV, inci-
(Fig. 1).
dence of adverse events and the amount of food intake
after surgery. The QoR-40 score 1 month after surgery The groups were comparable with respect to age, height,
was also recorded to evaluate the long-term effects of weight, BMI, American Society of Anesthesiologists

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 218 Kamiya et al.

Fig. 1

Enrolment Assessed for eligibility

(n = 79)

Excluded:
Not meeting inclusion criteria (n = 10)
Declined participation (n = 9)

Randomised
(n = 60)

Allocation
Allocated to levobupivacaine Allocated to normal saline
(n = 30) (n = 30)

Excluded:
Incomplete QoR
questionnaire
(n = 1)

Postoperative
assessment
Analysed (n = 29) Analysed (n = 30)

Lost to follow-up: Lost to follow-up:

Incomplete QoR Incomplete QoR
questionnaire questionnaire
(n = 5) (n = 9)

1-month
follow-up
Analysed (n = 24) Analysed (n = 21)

CONSORT flow diagram.

physical status and the surgical procedures performed
(Table 1).
Postoperative pain and requirement for intra-operative
anaesthesia
NRS scores were significantly lower at 6 h after surgery in
the PECS group than those in the control group (P ¼ 0.018,
Table 2); however, the pain-sparing effect of the PECS
block disappeared 24 h after surgery. The requirement for
rescue analgesia (nonsteroidal anti-inflammatory drugs,
acetaminophen, pentazocine) and the incidence of PONV
were not significantly different between the two groups
(Table 2). The mean remifentanil dose required were
almost identical between the groups, although the mean
propofol blood target concentration to maintain BIS
between 40 and 50 was significantly higher in the control
group than in the PECS group (Table 1).
Quality of recovery
The pre-operative global QoR-40 score was similar
between the two groups (Table 3). Contrary to our
expectation, the PECS block did not improve QoR-40
scores on POD 1 (182 [176 to 189] in the PECS group and
174.5 [157.75 to 175] in the control group; P ¼ 0.143,
Table 3). Of the five dimensions of the QoR-40, only
the psychological support score was significantly higher in
the PECS group when compared with the control group
(P ¼ 0.044). We also evaluated the change in QoR score

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 Pectoral nerve block and recovery from breast cancer surgery 219

Table 1 Patient demographic, operative and anaesthetic details Table 2 Postoperative Numeric Rating Scale pain scores,
postoperative requirement for rescue analgesics and incidence of
PECS group, Control group, P postoperative nausea and vomiting
Parameter n U 29 n U 30 value
Time (hour) PECS group Control group P value
Age (year) 54.5 (12.0) 53.3 (11.6) 0.71
Height (cm) 157.7 (5.9) 156.9 (5.2) 0.59 Postoperative pain (NRS)
Weight (kg) 57.3 (10.8) 54.1 (7.4) 0.18 0h 1 [1 to 3] 4 [1 to 5.75] 0.023
BMI (kg m2) 23.0 (3.71) 22.0 (3.25) 0.27 1h 2 [1 to 3] 3.5 [1.25 to 5] 0.084
ASA classification (I/II) 11/18 9/21 0.35 3h 1 [0 to 2] 1.5 [1 to 2.75] 0.39
Surgical procedures 0.22 6h 1 [0 to 2] 1 [0.25 to 2.75] 0.018
Partial mastectomy þ SNB 13 (44.8%) 9 (30.0%) 24 h 1 [0 to 2] 1 [0.25 to 2.75] 0.44
Partial mastectomy þ LND 3 (10.3%) 2 (6.7%) 48 h 1 [1 to 1] 1.5 [1 to 2] 0.44
Partial mastectomy 0 (0%) 1 (3.3%) 1 month 1 [0 to 1] 1 [1 to 2] 0.63
Mastectomy þ SNB 9 (31.0%) 13 (43.3%) Incidence of requirement for rescue analgesia
Mastectomy þ LND 4 (17.2%) 5 (16.7%) 0 to 24 h 10 (34.5%) 13 (44.8%) 0.3
Duration of anaesthesia (min) 189.4 (48.9) 178.9 (35.2) 0.34 24 to 48 h 2 (6.9%) 6 (20%) 0.14
Duration of surgery (min) 120.2 (45.4) 107.0 (35.6) 0.22 PONV
Propofol blood target 2.65 (0.52) 3.08 (0.41) <0.001 0 to 48 h 5 (17.2%) 10 (33.3%) 0.13
concentration to maintain
BIS 40 to 50 (mg ml1) The data are presented as the median [interquartile range] for postoperative pain
Required remifentanil 10.5 (4.28) 10.4 (4.68) 0.95 scores and as the number (proportion; %) for need for rescue analgesia and
dose (mg kg1 h1) incidence of PONV. The NRS analysis at 48 h after surgery was based on 21
patients in the PECS group and 25 patients in the control group. NRS, Numeric
The data are presented as the mean (SD) in each group. ASA, American Society Rating Scale; PECS, pectoral nerve block; PONV, postoperative nausea and
of Anesthesiologists; LND, axillary lymph node dissection; PECS, pectoral nerve vomiting.
block; SNB, sentinel lymph node biopsy.

(postoperative QoR score–pre-operative QoR score) in
each patient. Our results indicated that neither the global
score nor any of the scores for the five dimensions of the
QoR-40 were significantly improved in the PECS group
when compared with the control group (Table 3). The
differences in postoperative pain and QoR-40 scores
between the two groups disappeared by 1 month after
surgery (Tables 2 and 3).
We also evaluated the relationship between patient age
and QoR scores and found that the global, psychological
support and physical independence scores correlated
with patient age in the control group. However, these
correlations were not observed in the PECS group
(Fig. 2).
We also evaluated peri-operative food intake. Patients
were permitted to resume a normal diet on the morning
following the day of surgery. Food intake on POD 1 was
higher in the PECS group than in the control group,
but the difference was no longer present by POD 2
(Table 4).
Discussion
In this study, we evaluated the effects of PECS block
combined with general anaesthesia on postoperative pain

Table 3 40-Item quality of recovery questionnaire scores in the pectoral nerve group and the control group pre-operatively, and on
postoperative day 1 and 1 month after surgery

Absolute value, median [IQR] Difference, median [IQR]

PECS group Control group P value PECS group Control group P value
Pre-operative (n ¼ 29) (n ¼ 30)
Global (0 to 200) 186 [175 to 195] 184 [174 to 194] 0.44
Physical comfort (0 to 60) 55 [53 to 57] 56 [53.25 to 59] 0.17
Physical independence (0 to 25) 25 [23 to 25] 25 [23 to 25] 0.77
Emotional state (0 to 45) 40 [37 to 43] 39 [35.25 to 42] 0.28
Psychological support (0 to 35) 35 [31 to 35] 32.5 [28.25 to 3] 0.16
Pain (0 to 35) 33 [32 to 35] 34 [32 to 35] 0.99
Postoperative day 1 (n ¼ 29) (n ¼ 30) (n ¼ 29) (n ¼ 30)
Global 182 [176 to 189] 174.5 [157.75 to 175] 0.14 5 [11 to 0] 9 [17.75 to 3.25] 0.14
Physical comfort 55 [53 to 57] 53.5 [49 to 56] 0.27 2 [3 to 0] 3 [6.75 to 0] 0.32
Physical independence 23 [9 to 25] 21 [17.75 to 24] 0.16 1 [4 to 0] 2 [4.75 to 0.25] 0.11
Emotional state 41 [38 to 43] 39 [36 to 42] 0.23 1 [2 to þ3] 0 [3.75 to 2.75] 0.83
Psychological support 35 [32 to 35] 31.5 [28.25 to 35] 0.044 0 [0 to 0] 0 [1.75 to 0] 0.44
Pain 31 [29 to 32] 29 [27 to 32.75] 0.36 3 [4 to 0] 2 [7 to 1] 0.56
1 Month later (n ¼ 24) (n ¼ 21) (n ¼ 24) (n ¼ 21)
Global 186 [165.25 to 196.5] 184 [169 to 196] 0.87 þ1.5 [5.25 to þ5] þ2 [9 to þ11] 0.59
Physical comfort 56.5 [53 to 60] 58 [53 to 60] 0.56 þ1 [2.25 to þ2] 0 [4 to þ4] 0.66
Physical independence 25 [22 to 25] 25 [24 to 25] 0.53 2 [9 to 0] 1 [5 to 0] 0.52
Emotional state 41 [34.5 to 45] 39 [35 to 43] 0.92 1.25 [9 to 0] 3 [9 to 0] 0.61
Psychological support 33.5 [30.75 to 35] 34 [29 to 35] 0.4 1.25 [9 to 0] 3 [9 to 0] 0.5
Pain 32 [29.75 to 34.25] 33 [31 to 34] 0.43 3 [11 to 0.5] 3 [16 to 1] 0.61

The data are presented as the median [interquartile range]. IQR, interquartile range; PECS, pectoral nerve block; QoR-40, 40-item quality of recovery questionnaire.

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 220 Kamiya et al.

Fig. 2

Global score Psychological support Physical independence

40 10 5
Difference in QoR score

20 0
Control group

5
0
0 –5
–20
–5 –10
–40
–10 –15
–60
–80 –15 –20
30 40 50 60 70 80 30 40 50 60 70 80 30 40 50 60 70 80

40 10 5
Difference in QoR score

20
PECS group

5 0
0
0 –5
–20
–5 –10
–40
–60 –10 –15

–80 –15 –20

30 40 50 60 70 80 30 40 50 60 70 80 30 40 50 60 70 80

Patient age (year)

Correlation between patient age and difference in 40-item quality of recovery questionnaire scores in the pectoral nerve group and the control group.
In the control group, patient age was significantly correlated with the global, psychological support and physical independence scores on the 40-item
quality of recovery questionnaire. The correlation between patient age and change in 40-item quality of recovery questionnaire score was analysed
using Pearson’s test. The correlation coefficients (r2) in the pectoral nerve group are 0.176 for the global score (P ¼ 0.02), 0.177 for the
psychological support score (P ¼ 0.03) and 0.165 for the physical independence score (P ¼ 0.02). The correlation coefficients (r2) in the control
group are 0.0014 for the global score (P ¼ 0.85), 0.0074 for the psychological support score (P ¼ 0.65) and 0.054 for the physical independence
score (P ¼ 0.19).

as measured by the NRS and intra-operative doses of PECS block did not affect the intra-operative require-
propofol and remifentanil in a double-blind fashion. We ment for remifentanil despite decreasing postoperative
also evaluated the effects of PECS block on QoR using pain and the intra-operative requirement for propofol. A
the Japanese version of the QoR-40.19 PECS block could PECS block can block the lateral cutaneous branches of
reduce postoperative pain for up to 6 h after surgery as the spinal nerves at T2 to T6, and possibly the anterior
previously reported.15–17 Significantly, PECS block cutaneous branches if sufficient local anaesthetic pene-
decreased the requirement for propofol (as measured trates the external intercostal muscles.13,16,17 The long
by the mean blood target concentration to maintain thoracic nerve can be blocked by local anaesthetic agents
BIS between 40 and 50) but not that for remifentanil entering the axilla.13 However, the anterior cutaneous
during surgery. However, contrary to our expectation, branch of the spinal nerve may not be blocked if local
PECS block did not improve the total QoR-40 score on anaesthetic agents do not penetrate the external inter-
POD 1 after breast cancer surgery. costal muscles; if this is the case, anaesthesia in the

Table 4 Peri-operative meal intake in the pectoral nerve group and the control group

PECS group Control group P value

Supper, day before surgery 100 [88.75 to 100] 100 [92.5 to 100] 0.94
Breakfast, POD 1 100 [85 to 100] 92.5 [65.25 to 100] 0.061
Lunch, POD 1 100 [100 to 100] 75 [60 to 100] 0.024
Supper, POD 1 100 [100 to 100] 100 [75 to 100] 0.15
Breakfast, POD 2 100 [85 to100] 100 [75 to 100] 0.65

The data are presented as the median [interquartile range]. PECS, pectoral nerve block; POD 1, postoperative day 1; POD 2, postoperative day 2.

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 Pectoral nerve block and recovery from breast cancer surgery 221
medial part of the chest wall would be inadequate.16 Our
results may reflect the anatomic nature of the anterior
chest wall. The similar intra-operative requirement for
remifentanil in the two groups suggests that the surgical
invasion reached the medial part of the chest wall in
most patients.
The propofol dose-sparing observed in this study might
have been affected by the systemic effects of local
anaesthetics. The PECS block is one of the interfascial
plane blocks. Several reports have shown that the con-
centrations of local anaesthetic in the blood after a
transversus abdominis plane block, which is also an
interfascial plane block, were in the order of sub-mg ml1
to mg ml1.20,21 These low concentrations might affect
the ability of local anaesthetic agents circulating in the
systemic circulation to suppress functioning of the
sodium channel in the central nervous system, resulting
in sedation.22 – 24
In addition, the analgesic effect of PECS block did not
reflect improvement in the pain dimension of the QoR-40
score, even though the NRS score for postoperative pain
in the PECS group was significantly lower than that in the
control group in our study. ‘Rebound’ pain may account
for this finding. When a PECS block is effective, the
duration of analgesia has been reported to be up to 24 h.16
However, several studies, including a meta-analysis, have
shown that patients can suffer rebound pain after cessa-
tion of a nerve block or peri-articular injection.25–28 In our
study, the QoR-40 score on POD 1 was evaluated approx-
imately 24 h after surgery and by then the NRS score was
almost the same in the two groups. Postoperative pain
strongly affects QoR after surgery,1,29 and this may be a
reason why the global and pain dimensions of the QoR-40
scores on POD 1 were not significantly different between
the groups.
We evaluated the relationship between change in QoR
score (before surgery – POD 1) and patient age, and
found a negative correlation in the control group but no
correlation in the PECS group. This finding indicates that
a PECS block using 30 ml of 0.25% levobupivacaine is
somewhat effective for suppressing postsurgical discom-
fort, including postoperative pain. We speculate that
younger patients felt more intense pain after surgery
and that this affected the QoR findings in our study.
Several studies have indicated that younger patients who
undergo breast cancer surgery are more susceptible to
persistent postoperative pain.30–32
Postsurgical pain has been known to have a negative
impact on not only PONV and general fatigue but also
appetite in the early stages of recovery.33 Patients who
received a PECS block were more likely to have a
preserved appetite on POD 1 to 2 than those in the
control group in our study. Our anaesthesia protocol was
identical in the two study groups except that 0.25%
Eur J Anaesthesiol 2018; 35:215–223
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
levobupivacaine was used as the injectate for nerve block
in the PECS group. We speculated that the analgesic
effect of the PECS block might contribute to preserva-
tion of appetite. As indicated above, a patient’s appetite
might be reduced by postsurgical pain during recovery;
thus, reduction of postsurgical pain could preserve appe-
tite. An extensive study is needed to clarify the relation-
ship between postoperative pain and appetite.
There are several limitations to this study. First, we used
a multimodal peri-operative analgesic regimen including
acetaminophen, tramadol, diclofenac and dexametha-
sone in both groups. A recent study indicated that dexa-
methasone had not only antiemetic effects but also strong
analgesic effects in patients undergoing breast cancer
surgery.34 This might account for why we could not find
a large difference in postoperative pain between the two
groups. Moreover, steroids, including dexamethasone,
may improve QoR after surgery,35,36 and our multimodal
analgesia regimen may have influenced the small differ-
ences in QoR scores between the groups. We believed
that all the participants in the study should receive a
standardised peri-operative multimodal analgesic regi-
men even if it reduced the chances of finding a significant
difference between the intervention group and the con-
trol group. An essential goal of our study was to demon-
strate the benefit of adding a PECS block to a generally
accepted analgesic regimen in patients undergoing breast
cancer surgery, but we did not find the PECS block to be
of great benefit.
Second, we did not confirm the efficacy of the PECS
block before surgery, because we believed it to be a
compartment block with less risk of nerve injury and felt
that performing the block under general anaesthesia
would be more comfortable for the patients. Recent
studies have indicated that PECS block achieves loss
of sensation in the lateral part of the chest wall at the T2
to T6 level,17,18 and our block procedure was almost the
same as in those reports.
Third, the efficacy of PECS block could have been
potentiated by adding adjuvants to the local anaesthetic
agents. There have been some reports of dexametha-
sone,37 betamethasone38 and alpha-2 agonists39 prolong-
ing the effects of brachial plexus block when mixed with
local anaesthetics. However, there are some researches
suggesting that even systemically administered dexa-
methasone can prolong the effects of a peripheral nerve
block.40,41 Therefore, we did not mix adjuvants with the
local anaesthetic agents used in the current study.
Fourth, the sample size might have been too small to
determine the effectiveness of PECS block using
improvement in the QoR-40 score. Moreover, we should
have anticipated a higher dropout rate in the month after
breast cancer surgery when recruiting patients for this
study of the effects of PECS block.
 222 Kamiya et al.
As alluded to above, the limited distribution of the PECS
block may have been one of the reasons why there was no
significant difference in the intra-operative remifentanil
requirement between the groups. The ultrasound-guided
transversus thoracic muscle plane (TTP) block was
recently introduced to block the anterior cutaneous
branches of the intercostal nerve.42 A TTP block pro-
vides analgesia in the internal mammary area, which
cannot be reached by a PECS block. Combination of a
PECS block and a TTP block provides analgesia superior
to that of a PECS block alone.18 The potential ability of a
combination of these two blocks to improve analgesia and
QoR after breast cancer surgery warrants further investi-
gation in the future.
Conclusion
The PECS block was effective for reducing postopera-
tive pain. However, contrary to our expectation, a PECS
block combined with propofol–remifentanil anaesthesia
did not reduce the intra-operative use of remifentanil or
improve the postoperative QoR score when compared
with a saline-injected mock block. The absence of a
remifentanil-saving effect when using the PECS block
might stem from the inability of the PECS block to reach
the internal mammary area. Further, the failure of
the PECS block to improve the postoperative QoR
score might be attributable to factors that cannot be
measured by analgesia immediately after surgery, such
as rebound pain.
Acknowledgements relating to this article
Assistance with the study: the authors thank Editage for providing
editorial assistance.
Financial support and sponsorship: none.
Conflicts of interest: none.
Presentation: none.
References
1 Abdallah FW, Morgan PJ, Cil T, et al. Ultrasound-guided multilevel
paravertebral blocks and total intravenous anesthesia improve the quality of
recovery after ambulatory breast tumor resection. Anesthesiology 2014;
120:703–713.
2 Poleshuck EL, Katz J, Andrus CH, et al. Risk factors for chronic pain following
breast cancer surgery: a prospective study. J Pain 2006; 7:626–634.
3 Pusch F, Freitag H, Weinstabl C, et al. Single-injection paravertebral block
compared to general anaesthesia in breast surgery. Acta Anaesthesiol
Scand 1999; 43:770–774.
4 Weltz CR, Greengrass RA, Lyerly HK. Ambulatory surgical management of
breast carcinoma using paravertebral block. Ann Surg 1995; 222:19–26.
5 Ilfeld BM, Madison SJ, Suresh PJ, et al. Treatment of postmastectomy pain
with ambulatory continuous paravertebral nerve blocks: a randomized, triple-
masked, placebo-controlled study. Reg Anesth Pain Med 2014; 39:89–96.
6 Gornall BF, Myles PS, Smith CL, et al. Measurement of quality of recovery
using the QoR-40: a quantitative systematic review. Br J Anaesth 2013;
111:161–169.
7 Lee WK, Kim MS, Kang SW, et al. Type of anaesthesia and patient quality of
recovery: a randomized trial comparing propofol–remifentanil total i.v.
anaesthesia with desflurane anaesthesia. Br J Anaesth 2015; 114:663–668.
8 Murphy GS, Sherwani SS, Szokol JW, et al. Small-dose dexamethasone
improves quality of recovery scores after elective cardiac surgery: a
randomized, double-blind, placebo-controlled study. J Cardiothorac Vasc
Anesth 2011; 25:950–960.
Eur J Anaesthesiol 2018; 35:215–223
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
9 Murphy GS, Szokol JW, Greenberg SB, et al. Preoperative dexamethasone
enhances quality of recovery after laparoscopic cholecystectomy: effect on
in-hospital and postdischarge recovery outcomes. Anesthesiology 2011;
114:882–890.
10 Yoshida T, Shimizu H, Furutani K, et al. Unintentional epidural placement of
a thoracic paravertebral catheter inserted using an ultrasound-guided
technique: a case report. J Anesth 2016; 30:727–730.
11 Albi-Feldzer A, Duceau B, Nguessom W, et al. A severe complication after
ultrasound-guided thoracic paravertebral block for breast cancer surgery: total
spinal anaesthesia: a case report. Eur J Anaesthesiol 2016; 33:949–951.
12 Blanco R. The ‘PECS block’: a novel technique for providing analgesia after
breast surgery. Anaesthesia 2011; 66:847–848.
13 Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of PECS
II (modified PECS I): a novel approach to breast surgery. Rev Esp
Anestesiol Reanim 2012; 59:470–475.
14 Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: a novel ultrasound-
guided thoracic wall nerve block. Anaesthesia 2013; 68:1107–1113.
15 Morioka H, Kamiya Y, Yoshida T, et al. Pectoral nerve block combined with
general anesthesia for breast cancer surgery: a retrospective comparison.
JA Clin Rep 2015; 1:15.
16 Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal
analgesia for breast cancer surgery: a randomized clinical trial. Reg Anesth
Pain Med 2015; 40:68–74.
17 Kulhari S, Bharti N, Bala I, et al. Efficacy of pectoral nerve block versus thoracic
paravertebral block for postoperative analgesia after radical mastectomy: a
randomized controlled trial. Br J Anaesth 2016; 117:382–386.
18 Ueshima H, Otake H. Addition of transversus thoracic muscle plane block
to pectoral nerves block provides more effective perioperative pain relief
than pectoral nerves block alone for breast cancer surgery. Br J Anaesth
2017; 118:439–443.
19 Tanaka Y, Wakita T, Fukuhara S, et al. Validation of the Japanese version of
the quality of recovery score QoR-40. J Anesth 2011; 25:509–515.
20 Griffiths JD, Barron FA, Grant S, et al. Plasma ropivacaine concentrations
after ultrasound-guided transversus abdominis plane block. Br J Anaesth
2010; 105:853–856.
21 Corvetto MA, Echevarria GC, De La Fuente N, et al. Comparison of plasma
concentrations oflevobupivacainewithand without epinephrine for transversus
abdominis plane block. Reg Anesth Pain Med 2012; 37:633–637.
22 Goyal R, Shukla RN. Local anesthetic systemic toxicity (LAST) – should we
not be concerned? Med J Armed Forces India 2012; 68:371–375.
23 Stewart J, Kellett N, Castro D. The central nervous system and
cardiovascular effects of levobupivacaine and ropivacaine in healthy
volunteers. Anesth Analg 2003; 97:412–416.
24 Knudsen K, Beckman Suurküla M, Blomberg S, et al. Central nervous and
cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and
placebo in volunteers. Br J Anaesth 1997; 78:507–514.
25 Williams BA, Bottegal MT, Kentor ML, et al. Rebound pain scores as a
function of femoral nerve block duration after anterior cruciate ligament
reconstruction: retrospective analysis of a prospective, randomized clinical
trial. Reg Anesth Pain Med 2007; 32:186–192.
26 Abdallah FW, Halpern SH, Aoyama K, et al. Will the real benefits of single-
shot interscalene block please stand up? A systematic review and meta-
analysis. Anesth Analg 2015; 120:1114–1129.
27 McKeen DM, George RB, Boyd JC, et al. Transversus abdominis plane
block does not improve early or late pain outcomes after caesarean
delivery: a randomized controlled trial. Can J Anaesth 2014; 61:631–640.
28 Youm YS, Cho SD, Cho HY, et al. Preemptive femoral nerve block could
reduce the rebound pain after periarticular injection in total knee
arthroplasty. J Arthroplasty 2016; 31:1722–1726.
29 Onaka H, Ishikawa M, Mizuguchi Y, et al. Evaluation of postoperative pain
control and quality of recovery in patients using intravenous patient-
controlled analgesia with fentanyl: a prospective randomized study. J
Nippon Med Sch 2016; 83:158–166.
30 Macintyre PE, Jarvis DA. Age is the best predictor of postoperative
morphine requirements. Pain 1996; 64:357–364.
31 Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric
testing of a quality of recovery score after general anesthesia and surgery in
adults. Anesth Analg 1999; 88:83–90.
32 Chang KY, Dai CY, Ger LP, et al. Determinants of patient-controlled
epidural analgesia requirements: a prospective analysis of 1753 patients.
Clin J Pain 2006; 22:751–756.
33 Barthelsson C, Lutzen K, Anderberg B, et al. Patients’ experiences of
laparoscopic cholecystectomy in day surgery. J Clin Nurs 2003; 12:253–259.
34 Cortes-Flores AO, Jimenez-Tornero J, Morgan-Villela G, et al. Effects of
preoperative dexamethasone on postoperative pain, nausea, vomiting and
respiratory function in women undergoing conservative breast surgery for
cancer: results of a controlled clinical trial. Eur J Cancer Care (Engl) 2017;
00:e12686.
 Pectoral nerve block and recovery from breast cancer surgery 223

35 Mihara T, Ishii T, Ka K, et al. Effects of steroids on quality of recovery and
adverse events after general anesthesia: meta-analysis and trial
sequential analysis of randomized clinical trials. PLoS One 2016;
11:e0162961.
36 Joshi GP, Kehlet H. CON: perioperative goal-directed fluid therapy is an
essential element of an enhanced recovery protocol? Anesth Analg 2016;
122:1261–1263.
37 Huynh TM, Marret E, Bonnet F. Combination of dexamethasone
and local anaesthetic solution in peripheral nerve blocks: a meta-
analysis of randomised controlled trials. Eur J Anaesthesiol 2015;
32:751 – 758.
38 Watanabe K, Tokumine J, Yorozu T, et al. Particulate-steroid betamethasone
addedtoropivacaineininterscalenebrachialplexusblockforarthroscopicrotator
cuff repair improves postoperative analgesia. BMC Anesthesiol 2016; 16:84.
39 El-Boghdadly K, Brull R, Sehmbi H, et al. Perineural dexmedetomidine is
more effective than clonidine when added to local anesthetic for
supraclavicular brachial plexus block: a systematic review and meta-
analysis. Anesth Analg 2017; 124:2008–2020.
40 Desmet M, Braems H, Reynvoet M, et al. I.V. and perineural dexamethasone
are equivalent in increasing the analgesic duration of a single-shot
interscalene block with ropivacaine for shoulder surgery: a prospective,
randomized, placebo-controlled study. Br J Anaesth 2013; 111:445–452.
41 Baeriswyl M, Kirkham KR, Jacot-Guillarmod A, et al. Efficacy of perineural vs
systemic dexamethasone to prolong analgesia after peripheral nerve block:
a systematic review and meta-analysis. Br J Anaesth 2017; 119:183–191.
42 Ueshima H, Kitamura A. Blocking of multiple anterior branches of
intercostal nerves (Th2-6) using a transversus thoracic muscle plane block.
Reg Anesth Pain Med 2015; 40:388.

Eur J Anaesthesiol 2018; 35:215–223

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.