Après chirurgie du sein, la douleur postopératoire immédiate varie selon le type de chirurgie mais dépend également de nombreux autres facteurs comme l’âge de la patiente, son état anxio-dépressif, les troubles cognitifs et les traitements liés au cancer (radiothérapie, chimiothérapie) etc. La douleur est le plus souvent modérée (EVA ≈ 3) et peut être traitée par des antalgiques de pallier 1. Elle peut être intense et nécessiter un recours à la morphine, essentiellement après chirurgie majeure du sein. L’anesthésie loco régionale (ALR) a un intérêt majeur dans le cadre d’une prise en charge multimodale d’une chirurgie du sein. Il existe tout un panel de blocs : des infiltrations aux blocs périmédullaires, le choix du type d’ALR se fera selon la chirurgie prévue, les comorbidités du patient, l’expérience de l’anesthésiste et l’environnement structurel. L’infiltration d’un anesthésique local est un geste simple à faible risque de complications mais d’une efficacité limitée dans le temps. Les blocs serratus, inter- et serrato-pectoraux (anciennement dénommés PECS I et II) sont des techniques peu invasives et efficaces si les indications sont respectées. Le bloc paravertébral (BPV) thoracique, de réalisation plus délicate est recommandé (grade A) pour la gestion de la douleur après chirurgie majeure du sein. Récemment développé, le bloc des érecteurs du rachis ou Erector Spinae Plane block (ESP) est de réalisation facile mais avec une efficacité controversée pour la chirurgie du sein.

BACKGROUND:Preventing acute postsurgical pain (PSP) following breast cancer surgery is a major issue. Thoracic paravertebral block (TPVB) has been widely studied for this indication. Erector spinae plane block (ESPB) has been assumed to be effective. We aimed to compare the efficacy and safety of ESPB over TPVB in preventing acute PSP.METHODS:In this prospective observational study, 120 patients admitted for unilateral major oncologic breast surgery received T2/T3 ESPB (ropivacaine 0.75%, 0.35 ml.kg-1), and 102 were analysed. Then, the ESPB cohort was compared to a TPVB cohort from the experimental arm of a randomized controlled study with the same protocol (NCT02408393) using propensity score matching analysis. The primary outcome was the need for morphine consumption in the PACU. Secondary outcomes were the morphine total dose, the incidence of ESPB and TPVB complications, and discontinuous visual analogue scale measurement trends at rest and at mobilization in the 24 hours after surgery.RESULTS:A total of 102 patients completed the study between December 2018 and August 2019. Propensity score matching formed 94 matched pairs. The proportion of morphine titration in the PACU was higher in the ESPB group than in the TPVB group (74.5% vs. 41.5%, p<0.001), with a between-group difference of 33.0% (95% CI [19.3%, 46.7%]). No ESPB-related complications were observed.CONCLUSION:ESPB is less effective in preventing morphine consumption in the PACU than TPVB. Our findings do not support the use of ESPB as the first-line regional anaesthesia for major breast cancer surgery. Randomized trials comparing ESPB and TPVB are needed.

Acute pain after minor breast surgery is most often moderate (VAS <= 3). It can be severe (VAS > 3) when the surgery is major, requiring the use of morphine. The incidence of chronic pain 3 months after breast surgery is 30 %. Risk factors for postoperative pain are variable and depend on the type of surgery, the patient, the perioperative period and the treatments associated with cancer. The management of a patient undergoing breast surgery requires specific management related to cancer-related treatments. Local infiltration with a local anaesthetic is a simple, fast and low-risk of complications, but with limited effectiveness in time. Type 1 and 2 interpectoral blocks (PECS I and II) are minimally invasive techniques, easily achievable but only partially effective. The thoracic paravertebral (BPV) block, a more technically challenging technique, is recommended (grade 1-A) for pain management for major breast surgery. The Erector Spinae Plane (ESP) block, recently developed in breast surgery, is easy to perform but has controversial effectiveness. In the postoperative phase, a combination of paracetamol NSAIDs and dexamethasone are the mainstay of systemic analgesia. Regardless of the technique of regional anaesthesia and the associated treatments, management must be optimal. Future research should focus on postoperative rehabilitation, mainly postoperative pain management and risk of chronic pain.