Thoracic interfacial plane block versus thoracic paravertebral block for anesthesia in gynecomastia surgery: A randomized controlled trial

Taysser M Abdelraheem; Tamer Mohamed Naguib; Amira M Elkeblawy

doi:10.4103/bjoa.bjoa_271_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 7 | Issue : 1 | Page : 32-38

Thoracic interfacial plane block versus thoracic paravertebral block for anesthesia in gynecomastia surgery: A randomized controlled trial

Taysser M Abdelraheem, Tamer Mohamed Naguib, Amira M Elkeblawy
Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission	23-Dec-2022
Date of Decision	16-Jan-2023
Date of Acceptance	20-Jan-2023
Date of Web Publication	6-Mar-2023

Correspondence Address:
Taysser M Abdelraheem
Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta 31527
Egypt

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.bjoa_271_22

Abstract

Background: Gynecomastia is a benign proliferative condition affecting the glandular tissue of the male breast. This study compared the efficacy of ultrasound-guided thoracic interfacial plane block (TIPB) with ultrasound-guided thoracic paravertebral block (TPVB) in providing anesthesia for gynecomastia surgery. Materials and Methods: This prospective randomized open label clinical trial included 90 patients scheduled for elective surgery for idiopathic gynecomastia. Patients were randomly allocated into three equal groups: group C (control group) received bilateral tumescent local anesthesia, group TPVB received bilateral ultrasound guided TPVB, and group TIPB received bilateral ultrasound guided TIPB. We evaluated postoperative analgesic requirements, pain score, and patient’s satisfaction. Results: Intraoperative fentanyl requirement and total diclofenac in the first 24 hours postoperative were significantly lower in both TPVB and TIPB groups compared to control group (P = 0.002 and P < 0.001, respectively). Patient satisfaction was significantly better (P = 0.004) in both TPVB and TIPB groups when compared to control group. In postoperative evaluation, we found both TPVB and TIPB produced significantly lower pain score compared to control group in 2-hours (P < 0.001) and 4-hours (P = 0.001) after the surgery. Mean arterial blood pressure, heart rate, and peripheral oxygen saturation were comparable in all groups, as well as the occurrence of complications. Conclusion: Either TIPB and TPVB may provide effective analgesic property for anesthesia in gynecomastia surgery. This is shown by lower intraoperative analgesic requirements, lower postoperative pain score, and better patient’s satisfaction.

Keywords: Anesthesia, gynecomastia, thoracic interfascial plane block, thoracic paravertebral block

How to cite this article:
Abdelraheem TM, Naguib TM, Elkeblawy AM. Thoracic interfacial plane block versus thoracic paravertebral block for anesthesia in gynecomastia surgery: A randomized controlled trial. Bali J Anaesthesiol 2023;7:32-8

How to cite this URL:
Abdelraheem TM, Naguib TM, Elkeblawy AM. Thoracic interfacial plane block versus thoracic paravertebral block for anesthesia in gynecomastia surgery: A randomized controlled trial. Bali J Anaesthesiol [serial online] 2023 [cited 2023 Mar 21];7:32-8. Available from: https://www.bjoaonline.com/text.asp?2023/7/1/32/371184

Introduction

Gynecomastia is a benign proliferative condition affecting the glandular tissue of the male breast. It is categorized as physiologic (occurring normally during puberty, infancy, and older age) or pathologic (due to disorders such as androgen deficiency or due to drugs). Around 40% of cases are caused by persistent pubertal gynecomastia or medication side effects, whereas 25% are idiopathic.^[1] Surgical therapy should be considered and recommended in males whose gynecomastia does not regress spontaneously, and is causing psychological distress or considerable discomfort, or fibrotic stage has been reached. Many cases are treated with a combination of direct surgical excision of the glandular tissue and liposuction of any coexisting adipose tissue through a peri-areolar incision.^[2],[3]

The increasing prevalence of gynecomastia operations has raised the demand for anesthetic treatments that are safe, provide improved pain management, and are associated with fewer complications.^[4] Male breast surgery is often performed under combination of local infiltrative anesthesia or general anesthesia (GA) and intravenous sedation.^[5]

Non-steroidal anti-inflammatory drugs and opioids, which used following surgeries, have their limitations due to complications as respiratory depression, and vomiting.^[6] As a consequence of the reduced usage of opioid analgesics, for pain control after breast surgeries different thoracic nerve blocks give greater analgesic efficacy and reduced both nausea and vomiting postoperatively.^{[7],[8],[9],[10],[11],[12]}

Thoracic paravertebral block (TPVB) has been demonstrated to be more effective than conventional techniques in female mastectomy as it offers superior post-operative pain management and more surgical comfort.^[13] Early mobility and release may be advantages of TPVB in male patients after breast surgery. To our knowledge, only two cases of gynecomastia surgery have been performed under TPVB.^[5]

Thoracic interfascial plane block (TIPB) includes serratus-intercostal plane block (SIFB)^{[14],[15],[16],[17]} and pecto-intercostal fascial plane block (PIFB).^{[8],[18],[19]} SIFB targets pectoral nerve medial and lateral, the lateral cutaneous branch of the intercostal nerve, while PIFB targets the anterior cutaneous branch of the intercostal nerve. This study aimed to compare the efficacy of ultrasound guided TPVB and ultrasound guided TIPB for gynecomastia surgical anesthesia. To our knowledge, it is the first trial to study both TIPB and TPVB in gynecomastia surgeries.

Materials and Methods

This randomized trial was conducted on ninety male patients aged from 18 to 65 years, American Society of Anesthesiologists (ASA) physical status I and II, weight 75–100 kg scheduled for elective idiopathic gynecomastia surgery with duration of surgery ≤2 hours in Tanta University Hospitals during the period from June 2020 to December 2021. The study was done after approval from the Ethical Committee of Faculty of Medicine, Tanta University, Egypt (registry number 33793/4/20) and registered in Clinical Trial Registry (NCT04425447). Uncooperative subjects, injection site infection (TIPB or TPVB), known hypersensitivity to bupivacaine or lidocaine, coagulopathy and history of chronic analgesic use or opioid abuse were excluded [Figure 1].

Figure 1: Consort flowchart of the studied patients

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Through sealed opaque envelopes, patients were randomly allocated into three groups. Group C (control group, n = 27) received bilateral tumescent local anesthesia, group TPVB (n = 29) received bilateral US guided TPVB, and group TIPB (n = 29) received bilateral US guided TIPB]. Preoperative assessment was done by history taking, clinical examination, and laboratory investigations including complete blood count, prothrombin time, liver function tests, and kidney function tests. Using a numerical rating system (NRS), patients were taught how to rate their level of pain (the score was from 0 to 10, where 0 indicates no pain and 10 showed the worst pain ever).

On entering operating room: routine monitoring by electrocardiogram was performed, noninvasive blood pressure and pulse oximetry were applied, and an intravenous line was established. To get comfortable positioning during the needle insertion, patients were given IV midazolam 2 mg just before performing the block. In all groups, the anesthesia was done bilaterally before the start of surgery.

2 mL of 1% lidocaine was injected after disinfecting the area of skin, and wetting fluid was employed (lidocaine 2% 20 mL, normal saline 1000 mL and epinephrine 1 mg). A 25-gauge needle was used to initiate infiltration. The 25-gauge needles are rather painless and offer sufficient local anesthetic to allow a 20-gauge spinal needle to penetrate comfortably and completely. After briefly tumescenting the glandular nipple tissue, a larger (20-gauge) spinal needle may be more readily inserted into the otherwise dense and refractory tissue.

The paravertebral block was conducted seated. Disinfection of the thoracic paravertebral site was performed surgically. A linear high-frequency transducer was used in this study. The scanning method (longitudinal out-of-plane approach) was initiated 5–10 cm lateral to the spinous process in order to localize the rounded ribs and parietal pleura underneath. After that, the transducer is moved medially till the transverse processes are identified to be more squared in shape and located deeper within the ribs. Following identification of the transverse processes, the skin was injected with 2 mL of 1% lidocaine. A 100-mm, 22 G needle was slanted out of plane to establish contact with the transverse process at each level of T4, and then advanced 1–1.5 cm farther in search of a lack of resistance to inject 20 mL (15 mL bupivacaine 0.25% and 5 mL lidocaine 2%).

TIPB was performed supine with the ipsilateral upper limb abducted 90°. The pectoral area was surgically disinfected. 80 mL of local anesthesia (LA) was injected in total (70 mL bupivacaine 0.25% and 10 mL lidocaine 2%).

For SIFB performance, under the outer third of the clavicle the linear probe was positioned for anatomical landmarks detection, as pectoralis muscles, external intercostal muscle (EIM), serratus anterior muscle (SAM), thoraco-acromial artery, and second rib. Using the in-plane technique, in medial to lateral downward below the clavicle, a 22-gauge Quincke type spinal needle was placed. The needle tip was inserted between the SAM and the second rib or EIM.^[16] A 1–2 mL of LA was injected as a test bolus after confirming that the test dosage had diffused between SAM and external intercostal muscles, a total of 20 mL of LA was injected. After ensuring that the fascial plane had expanded, the needle was cautiously advanced toward the third and fourth ribs. After employing the in-plane method to implant a 22-gauge Quincke type spinal needle in the caudad direction, the needle point was found at the pectoralis muscles and second rib attachment site.^[18],[19] After ensuring that 1–2 mL of LA was dispersed uniformly across the pectoralis muscles and the EIM, a total of 20 mL of LA was injected. Once the fascial plane was adequately enlarged, the needle was gently repositioned caudad.

The anesthesia adequacy was determined by sensory loss in the operative field to pinprick sensation after 5 minutes of block administration. If the block fails (after 20 minutes of performing the block), the patient was excluded from follow-up and analysis of the study. A single experienced investigator had conducted the blocks to reduce the technique variation, yet he was omitted from postoperative review. Fentanyl 25 g IV was administered if the patient complained of discomfort. If this occurs again, GA was performed, and the patient was thereafter eliminated from follow-up and analysis. Patients were moved to the post-anesthesia care facility following surgery (PACU).

NRS score was used to assess postoperative pain, if the score was above three, as rescue analgesia, intramuscular diclofenac sodium 75 mg was given (maximum 75 mg/8 hours). Chest X-ray was performed in TPVB group after discharge from PACU to exclude pneumothorax. Postoperative pain was assessed by NRS at admission to PACU and 1, 2, 4, 6, 8, 12, 18, and 24 hours in the surgical ward till discharge. Total of doses of postoperative diclofenac as a rescue analgesia were recorded. Heart rate, mean arterial blood pressure and peripheral oxygen saturation were measured pre–procedure and every 15 minute to the surgery end. A five-point verbal scale was employed to measure patient satisfaction, (with 1 indicating extreme dissatisfaction and 5 indicating extreme happiness). The primary outcome was intraoperative fentanyl requirement, and the secondary outcomes were patient’s satisfaction and postoperative analgesic requirement.

SPSS v28.0 (IBM, Chicago, IL) was used for statistical analysis. To determine the normality of the data distribution, histograms and Shapiro–Wilks test were performed. The mean and standard deviation (SD) of quantitative parametric data were analyzed using the analysis of variance test with post hoc (Tukey). Quantitative non-parametric data were presented as median and interquartile range (IQR) and were analyzed by Kruskal–Wallis test with Mann–Whitney test to compare each group. Chi-square test was used to analyze variables that were qualitative, which also were presented as percentage and frequency. P value < 0.05 stated significant.

Results

127 participants were screened for participation; 31 patients did not meet the inclusion criteria, and six patients declined to participate. Three groups of 90 patients were randomly assigned. Three patients in group C, one in group TPVB, and one in group TIPB were eliminated from the study and were treated with GA. 85 patients were monitored and statistical analysis was performed.

Demographic data (age, weight, height, body mass index, and ASA physical status), duration of surgery and onset of the blocks were comparable among the three studied groups. Duration of performing the block was statically insignificant different between TPVB and TIPB groups. Time till home discharge was statically significant earlier in TPVB and TIPB groups when compared to the controls with an insignificant difference between group TPVB and group TIPB [Table 1].

Table 1: Patient characteristics, analgesic requirements, and patient satisfaction

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The median NRS values were insignificantly different at PACU, 1 hour, 6 hour, 8 hour, 12 hour, 18 hour, and at 24 hour among the three studied groups. The median NRS values were significantly lower in group TPVB and group TIPB at 2- and 4-hours compared to group C with an insignificant difference between group TPVB and group TIPB [Table 2]. Intraoperative fentanyl requirement was significantly lower in TPVB and group TIPB compared to group C (P = 0.002). Total dose of diclofenac in the first 24 hours consumption postoperative was statically significantly (P < 0.001) lower in both intervention groups compared to control group with an insignificant difference between group TPVB and group TIPB.

Table 2: Postoperative numerical rating scale (NRS) among three groups

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The preoperative mean heart rate and mean arterial pressure were insignificantly different among the three groups. Intraoperative heart rate and mean arterial pressure at 15 and 30 minutes were statically significantly lower in TPVB and TIPB when compared to the controls while insignificantly different among the three studied groups at 45 minutes, 60 minutes and at the end. Peripheral oxygen saturation was insignificantly different among the three studied groups [Figure 2].

Figure 2: Comparison of (a) heart rate, (b) mean arterial blood pressure, and (c) Peripheral oxygen saturation among the three groups

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Patient satisfaction was statically and significantly better in TPVB and TIPB groups compared to the controls with an insignificant difference between group TPVB and group TIPB [Table 1]. As regards complications, postoperative nausea and vomiting occurred in 3 (11.1%) patients in group C, 2 (6.9%) patients in group TPVB and 2 (6.9%) patients in group TIPB (P = 0.805) while pneumothorax, local anesthetic toxicity, and respiratory depression did not occur in any group.

Discussion

In the present study, the median NRS values, intraoperative fentanyl requirement, the total dose of diclofenac in the first 24 hours consumption postoperative, intraoperative hemodynamics (heart rate and mean arterial pressure), and postoperative complications were significantly lower in both intervention groups compared to controls. Also, patients’ satisfaction was significantly better in the intervention groups compared to the controls.

By injecting a local anesthetic into the thoracic paravertebral region, a block adequate for breast surgery may simply be established without causing substantial ill effects. Paravertebral block is the only technique capable of completely eliminating cerebral responses to thoracic dermatomal stimulation. It is associated with a decrease in the use of opioids to manage postoperative pain, a decrease in postoperative pulmonary problems, a decrease in the length of stay in the post-anesthesia care unit (PACU), and lastly, a better patient outcome.^[20] A case report^[5] reported the use of nerve-stimulator-guided TPVB to conduct gynecomastia surgery. It indicated that both patients had efficient block and recovered well postoperatively, were discharged the same day, and experienced prolonged postoperative pain relief without experiencing block-related problems.

Moreover, Singh et al.^[21] in their meta-analysis found that TIPB showed a decreased intraoperative fentanyl consumption over intravenous analgesia and TPVB group. Postoperatively, 24-h opioid consumption with TIPB group was lower than intravenous analgesia but was higher than TPVB group. Two cases of pneumothorax were reported with TPVB.

Similar to our results, Woodworth et al.^[22] supported TPVB in their systematic review as a perioperatively effective analgesic technique to be performed in breast surgeries. They stated also that it decreased hospital stay and postoperative complications. They concluded that TPVB could provide safe surgical anesthesia and can eliminate the chronic pain after surgery. Furthermore, Kim et al.^[23] found that the pain score was significantly lower in the TIPB group than intravenous patient-controlled analgesia group with no statically significant differences in the requirement for additional analgesics and postoperative nausea and vomiting between the groups in the post-anesthesia care unit in patients underwent lumpectomy.

The capability of TPVB to reduce the intensity of postmastectomy pain was demonstrated by Hetta et al.^[24] There was significant decrease in pain score in TPVB group compared to pectoralis-serratus inter-fascial plane block group. 24-hour opioid consumption postoperatively had significantly decreased in TPVB group when compared to the other intervention group. Also, Naja et al.^[25] found that the pain scores both at rest and at movement had significantly decreased in TPVB compared to the other group receiving GA. Patients receiving TPVB required considerably less supplementary opioid administration than patients receiving GA. However, they also mentioned that the TPVB group had a considerably higher rate of postoperative nausea and vomiting-free patients (93%) compared to the general anesthetic group (67%).

Shokri et al.^.[26] evaluated the effectiveness and safety of serratus intercostals plane block against local wound infiltration. They discovered that the serratus intercostal plane block produced considerably lower intraoperative pain and postoperative patient satisfaction levels than the infiltration group. Moreover, the whole rescue analgesic dosage was substantially lower than in the infiltration group. Additionally, they found a significant difference in the incidence of vomiting across the study groups.

However, Hamed et al.^.[27] showed that TPVB produced higher pain score. A higher dose of opioids were given to the same group with a decrease in systolic blood pressure postoperatively in patients undergoing modified radical mastectomy.

Hong et al.^.[19] reported that TIPB provides effective analgesia following major breast surgeries with a substantial decrease in postoperative opioid consumption and pain score over 48 hours postoperatively. The patient reported no pain during surgical site dressing or mild percussion as a result of decreased sensation. Additional analgesics were not necessary and feeling at the surgical site was restored the next day. Moreover, Das et al.^[28] found that the total rescue analgesic requirements in first 24 hours were less in unilateral TPVB group as compared in GA group in patients scheduled for unilateral breast surgery.

Our study poses some limitations. This was a single center study, it declared an exclusive use of the blocks in male breast surgeries and may need further studies with increasing sample size, more randomized trials need to be conducted to verify the findings of our study. Our study focused on short-term outcomes for the first 24 hours after surgery and long-term outcomes are still unclear.

Conclusion

Both TIPB and TPVB are effective in anesthesia for gynecomastia surgery as they provide a longer duration of analgesia with lower pain score, lower fentanyl and diclofenac consumption, better satisfaction, and lower time till home discharge score in patients following gynecomastia surgery.

Financial support and sponsorship

Nil.

Conflict of interests

There are no conflicts of interest.

Author contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Ethical approval and protocol registration

The study was done after approval from the Ethical Committee of Faculty of Medicine, Tanta University, Egypt (code: 33793/4/20) and registration on clinicaltrials.gov (ID: NCT04425447).

Availability of data and material

The datasets used and/or analyzed during the current study are available as MS Excel files (.xlsx) from the corresponding author upon reasonable request.

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