Pain management after major oncological breast surgery: an updated systematic review and procedure specific postoperative pain management (PROSPECT) recommendations.

INTRODUCTION

Major oncological breast surgery can be associated with significant postoperative pain. The aim of this systematic review was to update existing recommendations for postoperative pain management after major oncological breast surgery.

METHODS

A systematic review was undertaken following PROcedure SPECific postoperative pain managemenT (PROSPECT) methodology. Randomised controlled trials and systematic reviews that investigated peri-operative analgesic, anaesthetic and surgical interventions were included. The evidence for these interventions was reviewed using a modified Delphi process for their invasiveness, efficacy, adverse effects and complications.

RESULTS

In total, 176 randomised controlled trials and eight systematic reviews were included. Analgesia with paracetamol, nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors, and dexamethasone continues to be advocated. Given the occurrence of problematic adverse effects, gabapentin is no longer recommended. Single-shot erector spinae plane block; interpectoral plane and pectoserratus plane block; superficial serratus anterior plane block; deep serratus anterior plane block; thoracic paravertebral block; and local infiltration analgesia are recommended. We no longer recommend a continuous thoracic paravertebral block, as single-shot regional analgesic modalities are sufficient to cover the worst part of the acute pain trajectory. Physiotherapy in the pre-operative and postoperative period is recommended. No perineural adjuncts; specific surgical techniques; or complementary medicine therapies are recommended.

DISCUSSION: The updated PROSPECT recommendations for pain management following major oncological breast surgery include pre- or intra- and postoperative administration of paracetamol; nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors; dexamethasone; single-shot regional analgesic techniques; and physiotherapy. The value of regional analgesic techniques is underlined, but the listed single-shot regional analgesic techniques are considered equivalent to each other.