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22]
Pectoral nerve block for postoperative analgesia in breast
cancer surgery
Mohamed O. Alfya, Manal Foadb
Background Breast cancer is the most common malignancy
in women and its incidence continues to increase. Surgery is
one of the mainstays of treatment of breast cancer, and
modified radical mastectomy is one of the standard
treatments, Pectoral nerve (PECS I and PECS II) block was
reported to be good analgesia for breast surgery.
Aim To compare PECS blocks in combination with general
anesthesia versus general anesthesia alone in modified
radical mastectomy surgery.
Patients and methods Patients were classified randomly
into two groups in a blinded manner, and each one contained
30 patients. Control group received general anesthesia only.
PECS group received general anesthesia plus PECS guided
by ultrasound (PECS I and PECS II).
Results There was a statistically significant decrease in
fentanyl requirement in the PECS group compared with the
control group. There was a high statistically significant
decrease in visual analog scale in the PECS group compared
with the control group. There was a statistically significant
increase the first time of rescue dose of opioid in PECS group
compared with control group.
Introduction
Breast cancer is the most common malignancy in
women, and it is incidence continues to increase.
Surgery is one of the mainstays of treatment of
breast cancer, and modified radical mastectomy
(MRM) is one of the standard treatments for
multicentric disease or tumors with extensive
coexistent ductal carcinoma in situ, where
achieving a clear surgical margin becomes difficult
with a segmental mastectomy. It is also indicated
for individuals who are not candidates for
radiation therapy, including those with active
scleroderma, history of prior radiotherapy, and
recurrent cases [1].
The growing increase in the number of breast surgeries
as therapy for breast cancer and cosmetic purposes has
resulted in an increased need for anesthetic techniques
with improved pain reduction, safety, and fewer
complications [2].
In breast surgery, acute postoperative pain from injured
muscles and nerves is a consistent risk factor for chronic
pain in association with its severity. Postoperative pain
can seriously reduce the life quality, and acute pain can
change into chronic pain syndrome. Management of
acute postoperative pain is required for a better
outcome and patients’ satisfaction. Regional
© 2020 The Scientific Journal of Al-Azhar Medical Faculty, Girls | Published by Wolters Kluwer - Medknow
Original article 71
Conclusion PECS blocks can produce excellent pain relief
during postoperative hours. They hold great promise as under
ultrasonic guidance they have become simple and easy-to-
learn techniques.
Sci J Al-Azhar Med Fac, Girls 2020 4:71–77
© 2020 The Scientific Journal of Al-Azhar Medical Faculty,
Girls
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2020 4:71–77
Keywords: general anesthesia, modified radical mastectomy, pectoral nerve I
block, pectoral nerve II block
Departments of, aSurgery, bAnesthesiology and Intensive Care, Al Zahraa
University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo,
Egypt
Correspondence to Mohamed O. Alfy, MD, Shoubra, Cairo Egypt. Tel:
+201004053236; fax: +20242221324;
e-mail: dromaralfy@yahoo.com
Received: 24 January 2020 Revised: 7 February 2020
Accepted: 9 February 2020 Published: 20 April 2020
techniques are regarded as the best choice to reduce
postoperative pain [3].
Thoracic epidural and thoracic paravertebral
techniques are widely used for anesthesia and
postoperative pain management for breast cancer
surgery, but not all anesthesiologists feel comfortable
using such invasive techniques [4].
Blanco [5] have described pectoral nerve (PECS) I
block aiming by injection an interfacial plane between
the pectoralis major and pectoralis minor muscles
targeting to block the lateral region of the breast to
provide analgesia for breast surgery. Subsequently, with
the inclusion of PECS I block as the first injection, a
second injection at the interfascial plane between the
pectoralis minor muscle and serratus anterior muscle
(PECS II block) for analgesia of the axilla was reported
to be good analgesia for breast surgery [6]. This block is
commonly performed using an in-line needling
technique by ultrasound guidance, which is essential
to identify the plane between the pectoralis major,
This is an open access journal, and articles are distributed under the terms
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License, which allows others to remix, tweak, and build upon the work
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DOI: 10.4103/sjamf.sjamf_7_20
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72 The Scientific Journal of Al-Azhar Medical Faculty, Girls, Vol. 4 No. 1, January-March 2020
minor muscles, and serratus anterior as well as the
anatomical landmarks associated with them. Bashandy
and Abbas [7] reported that PECS I and PECS II are
able to reduce intraoperative fentanyl requirement,
postoperative pain, morphine consumption, and
postoperative nausea and vomiting (PONV) in
patients undergoing breast cancer surgery; however,
hematoma and local anesthetic toxicity are still the
added risks of pneumothorax in PECS II block, which
may be reduced by using ultrasound guidance and
decreasing anesthetic concentration.
This current study prospectively aimed to compare
PECS blocks in combination with general anesthesia
versus general anesthesia alone in MRM surgery. The
primary outcome was to measure visual analog scale
(VAS) pain scores on a postoperative day, and the
secondary outcomes were to measure perioperative
opioid consumption, first rescue dose of analgesia,
hemodynamics, and PONV.
Patients and methods
This randomized, prospective double-blind clinical
study was carried at Al-Zahraa University Hospital,
Cairo, Egypt, between March 2018 and March 2019.
After obtaining approval from the hospital ethical
committee, written informed consents were obtained
from 60 female patients aged between 40 and 70 years,
with American Society of Anesthesiologists status I or
II, who were scheduled for breast surgeries. All
selected patients presented with breast cancer which
was diagnosed by clinical examination, ultrasound
scan, and mammography and confirmed by
histopathological examination of the biopsy taken.
Exclusion criteria
American Society of Anesthesiologists physical status
more than or equal to 3 (e.g. cardiac disease), allergy
to the drugs used in the study, coagulation
abnormality, history of alcohol or drug abuse,
uncontrolled diabetes mellitus or hypertension,
local infection at the site of block, BMI more than
30 kg/m2, and patients who refused to participate in
the study were excluded.
The patients were randomly divided into two groups
(using closed envelopes), and each one contained 30
patients. Control group received general anesthesia
only. PECS group received general anesthesia plus
PECS guided by ultrasound. Sonos cape A5 US
device, manufactured by Sono Scape Medical Corp.
(Shanghai, China), with liner array probe 5–10 MHz
was used, with an imaging depth of 4–6 mm.
In the recovery unit, a 20-G cannula was inserted, and
all patients were premedicated with midazolam 2 mg
and metoclopramide 10 mg. In the operating room
(OR), standard monitoring, including ECG, pulse
oximetry, noninvasive blood pressure measurement,
and capnography, was applied to the patient using
Drager Infinity Vista XL monitor (Drager Medical
System Inc., Telford, Pennsylvania, USA).
Technique
Pectoral nerve technique
After cleaning infraclavicular and axillary regions with
chlorhexidine, the probe was placed below the lateral
third of the clavicle. After recognition of the
appropriate anatomical structures, the skin puncture
point was infiltrated with 2% lignocaine and then the
block was performed by using a 20-G Tuohy needle.
The needle was advanced to the tissue plane between
pectoralis major and pectoralis minor muscles, and
injection of 10 ml of bupivacaine 0.25% after
negative aspiration for blood (PECS I) near the
pectoral muscles was deposited, and 20 ml of
bupivacaine 0.25% was deposited at the level of the
third rib between pectoralis minor and serratus anterior
muscles (PECS II).
General anesthetic technique
Intravenous induction of general anesthesia in each
group was performed by injection of fentanyl 1 μg/kg
intravenous, propofol 2 mg/kg intravenous, and
atracurium 0.5 mg/kg with the insertion of the
endotracheal tube of suitable size and connection to
a mechanical ventilator. The respiratory rate and tidal
volume were adjusted to maintain the end-tidal CO2
within 10% variation from baseline values. Intravenous
fluid therapy, transfusions, and other procedures
followed the usual standards.
Maintenance of anesthesia was performed using
Drager Fabius Plus Anesthetic Machine (Drager
Medical System Inc.). Mechanical ventilation was
initiated with a tidal volume of 8–10 ml/kg and an
inspired oxygen fraction of 0.5 at a 3 l fresh gas flow,
with isoflurane 1–2% and 0.1 mg/kg atracurium as top-
up doses for muscle relaxation. Hemodynamic variables
within 20% of baseline values were maintained, and
maintenance of anesthetic depth between 40 and 60%
was done by using bispectral index.
Modified radical mastectomy
The first step is the creation of skin flaps which are
marked preoperatively. The skin is incised with a
scalpel, and flaps are raised with either scalpel or
electrocautery. The superior extent of dissection is
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PECS blocks as postoperative analgesia Alfy and Foad 73

the position where the superficial fascia fuses with the group was lower in the first 12 h after surgery, with
pectoralis fascia. The inferior extent of the dissection is mean±SD of 2.8±1.2, than in the control group, with
the fusion of the breast fascia with that over the rectus mean±SD of 4.15±1.8, with P value=0.040. According
abdominus. Electrocautery is used to divide the fascia to the previous study and by adjusting the confidence
over the pectoralis muscle and remove it with the breast. interval to 95% type I error to 5, power of the test to
90% and the ratio between case and control to 1 : 1; the
The axilla is first entered by opening the clavipectoral total sample size required for this study was found to be
fascia. Axillary vein is identified as it runs posterior to 54 cases, divided into two equal groups, with 27
the pectoralis muscle, with careful blunt dissection and patients in each group.
retraction inferiorly of the axillary contents. Once
identified, carefully preserving its branches, the long Statistical analysis
thoracic nerve should be preserved. After that, the Data were collected, revised, coded, and entered the
axillary contents are dissected off the thoracodorsal Statistical Package for Social Science (IBM SPSS),
bundle superiorly and medially up to the level of the version 23 (IBM Corp., Armonk, New York, USA)
axillary vein and the specimen is handed off. Once the The quantitative data were presented as mean, SDs,
axillary dissection is completed, two drains are placed: and ranges when parametric and median and
one in the axilla and one anterior to the pectoralis interquartile range when data were nonparametric.
muscle. The skin is then closed in an interrupted The comparison between two groups regarding
fashion. quantitative data with parametric distribution was
done by using independent t test, whereas
At the end of the procedure, neostigmine was given to nonparametric distribution was done by using the
reverse neuromuscular block (0.05 mg/kg) with Mann–Whitney test. The confidence interval was set
atropine (0.01 mg/kg intravenous). Endotracheal to 95% and the margin of error accepted was set to 5%. So,
tube extubation was done, and then the patient was the P value was considered significant at less than 0.05.
transferred to PACU. Patients were strongly advised
that they should ask for analgesia if needed at any time
after the surgery. If pain was not relieved by diclofenac Results
sodium, morphine (5 mg) intramuscular was Regarding demographic data, there was no statistically
administered. Nausea and vomiting were treated significant difference between two groups, as shown in
using intramuscular metoclopramide 10 mg if PONV Table 1.
were present.
Regarding intraoperative fentanyl used to maintain
Assessment parameters systolic blood pressure between 100 and 140 mmHg,
Intraoperative fentanyl was given to maintain heart rate there was a highly statistically significant decrease in
(HR) and mean arterial pressure (MAP) values within fentanyl requirement in the PECS group compared
20% of the baseline. Hemodynamics (HR and MAP) with the control group, as shown in Fig. 1.
were measured at baseline, at 15, 30, 45, 60, 75, and
90 min postinduction and 1, 3, 6, 12, and 24 h Regarding HR and MAP, there were significantly
postoperatively. VAS scale at 0, 2, 4, 8, 12, and 24 h more stable HR and MAP at 15 min postinduction
was used to assess the pain intensity. First rescue dose of general anesthesia till 6 h postoperatively, whereas
of analgesia, total morphine consumption to maintain there were nonsignificant differences between the two
VAS=4 or less, PONV score (0=no nausea and groups at baseline and 12 and 24 h postoperatively, as
vomiting, 1=mild nausea, 2=severe nausea, shown in Figs 2 and 3.
3=vomiting once, and 4=repeated vomiting) and
complications related to the used procedure were
recorded. Table 1 Comparison of demographic data between the two
groups (mean±SD)
Control group PECS group Test P
Sample size calculation
(N=30) (N=30) value value
The sample size was calculated using PASS statistical
Age 49.66±11.00 49.90±13.00 0.072 0.939
program (NCSS, LLC The company is led by Dr. Jerry
Weight (kg) 77.50±2.00 76.45±3.00 −1.595 0.116
Hintze https://www.ncss.com/) for sample size Height (cm) 162.00±7.00 162.00±3.00 0.000 1.000
calculation, version 19.0.3 and according to a study Duration of 111.00±18.00 110.00±20.00 −0.204 0.839
done by Bashandy and Abbas, who mentioned that the surgery
postoperative morphine consumption in the PECS PECS, pectoral nerve. P value more than 0.05 (nonsignificant).
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74 The Scientific Journal of Al-Azhar Medical Faculty, Girls, Vol. 4 No. 1, January-March 2020
Figure 1
Intraoperative fentanyl requirement to maintain SBP between 100
and 140 mmHg. SBP, systolic blood pressure.
Regarding VAS at 0, 2, 4, 8, 12, and 24 h
postoperatively, there was a highly statistically
significant decrease in VAS in PECS group
compared with the control group at 2 and 12 h
postoperative, whereas there was a statistically
significant decrease in VAS in PECS group
compared with the control group at 0, 4, 8, and 24 h
postoperatively, as shown in Table 2.
Regarding first time of rescue dose of analgesia and total
morphine consumption to maintain postoperative
VAS=4 or less, there was a statistically significant
increase in the first time of rescue dose of opioid in
PECS group compared with the control group, as shown
in Fig. 4, whereas there was a statistically significant
decrease in total morphine consumption to maintain
postoperative VAS=4 or less in PECS group compared
with the control group, as shown in Table 3.
Regarding PONV, there was a statistically significant
decrease in the incidence of PONV in the PECS group
compared with the control group, as shown in Fig. 5.
Discussion
Effective postoperative pain control can prevent the
negative psychological and physiological consequences
that can occur. Good postoperative pain control
suppresses the stress response to surgery and reduces
the need for opioids and can protect immunity. The
severity of acute pain can be reduced using regional
anesthesia techniques, and this leads to less chronic
pain, and also PECS block effectively reduces the
incidence of PONV and improves the patient’s
quality of life [8].
Regarding intraoperative fentanyl used, postoperative
first time of rescue dose of analgesia, and total
morphine consumption to maintain postoperative
VAS=4 or less, in the current study, there was a
highly statistically significant decrease in
intraoperative fentanyl used in PECS group
compared with the control group. Regarding first
time of rescue dose of analgesia and total morphine
consumption to maintain postoperative VAS=4 or less,
there was a statistically significant increase in first time
of rescue dose of opioid in PECS group compared with
the control group, whereas there was a statistically
significant decrease in total morphine consumption
to maintain postoperative VAS=4 or less in PECS
group compared with the control group.
These results agree with Bashandy and Abbas [7], as
they found that the mean intraoperative fentanyl
consumption and the total amount of postoperative
morphine were significantly lower in the PECS group
than in the general anesthesia group. They reported
that combined PECS block with general anesthesia
produced excellent analgesia for breast surgery with
axillary dissection.
Moreover, Kulhari et al [9] studied the effect of PECS
block versus thoracic paravertebral block using
ropivacaine 0.5% for postoperative analgesia after
MRM, and found that the 24-h morphine
consumption was decreased, and the duration of
analgesia was significantly longer in patients who
received the PECS. Moreover, Chakraborty et al.
[10], in their study on a single injection of PECS
block, showed that the pain-free duration extended to
24 h after PECS injection. These results were matched
with Pedrosa [11] who found that the PECS block is
an effective analgesic technique that allows decreased
opioid consumption and its adverse effects, and he
demonstrated that it should be considered as an
alternative to conventional analgesia.
Moreover, Yuki et al. [12] studied PECS block versus
general anesthesia in breast cancer surgery using 0.25%
levobupivacaine, and they found that the mean fentanyl
consumption was significantly lesser in the PECS
group compared with the general anesthesia group,
which was 280.37±44.38 and 304.91±60.35,
respectively, and significantly lower postoperative
analgesia in PECS group.
Moreover, Zhao et al. [13], in their meta-analysis,
found that especially the PECS II block combined
with general anesthesia was safe and effective option
for analgesia in MRM compared with the control
group, which was anesthetized by general anesthesia
alone. PECS block was more effective in reducing
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PECS blocks as postoperative analgesia Alfy and Foad 75

Figure 2

Comparison between the two groups regarding mean HR. HR, heart rate.

Figure 3

Comparison between the two groups regarding MAP. MAP, mean arterial pressure.

Table 2 Comparison of visual analog scale at 0, 2, 4, 8, 12, and 24 h postoperatively [mean (range)]
VAS score Control group (N=30) PECS group (N=30) Test value P value
0h 3 (2–4) 1 (1–2) 3.017 0.032*
2h 5 (4–5) 1.5 (1–2) 5.149 0.006**
4h 3.4 (3–3.5) 2.5 (2–3) 2.898 0.041*
8h 2.9 (2.5–3) 2.3 (2–3) 3.156 0.018*
12 h 2.5 (2–3) 1.5 (1–2) 4.386 0.008**
24 h 2 (2–3) 1.5 (1–2) 2.674 0.044*
PECS, pectoral nerve; VAS, visual analog scale. *P value less than 0.05 (significant). **P value less than 0.01 (highly significant).

intraoperative and postoperative opioid consumption
(0–6 h) and incidence of PONV.
On the contrary, Morioka et al. [14] found no
change in the intraoperative fentanyl consumption
or the postoperative opioid supplement, and no
statistically significant differences regarding
PONV during their study on PECS combined
with total intravenous anesthesia versus total
intravenous anesthesia only for cancer breast.
Moreover, they showed no difference in
intraoperative fentanyl dose. Moreover, in PECS,
the escape of the anterior divisions of intercostal
nerves from the block made the pain to be the same
over the sternum in all groups with the same opioid
requirement.
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76 The Scientific Journal of Al-Azhar Medical Faculty, Girls, Vol. 4 No. 1, January-March 2020

Figure 4 Table 3 Comparison of total morphine consumption between

the two groups
Postoperative Control PECS Test P
morphine group group value value
consumption (mg) (N=30) (N=30)
Mean±SD 7.80±2.70 3.10 3872.983 <0.001
±2.70
PECS, pectoral nerve. P value less than 0.01 (highly significant).

surgical anesthesia with prolonged postoperative

analgesic period. Fujiwara et al. [16] found that
PECS produces hemodynamic stability in their study
on the comparison between intercostal nerve block
Comparison of the first time of rescue dose of analgesia between two
versus PECS block effect on cardiac
groups. resynchronization therapy device. This can be
explained by the fact that PECS is a nerve block
Figure 5 that causes no sympathetic affection and no
hemodynamic changes.

Regarding PONV; there was a statistically significant

decrease in the incidence of PONV in the PECS group
compared with the control group.

Other studies [7–13] examined MRM patients under

general anesthesia with or without PECS blocks and
found lower PONV scores in the PECS group.

Comparison of PONV between two groups. PONV, postoperative
nausea and vomiting.
Regarding VAS score, the current study shows there
was a high statistically significant decrease in VAS in
the PECS group compared with the control group at 2
and 12 h postoperatively, whereas there were
statistically significant decreases in VAS in PECS
group compared with the control group at 0, 4, 8,
and 24 h postoperatively. These results matched with
other studies [7–14], where they studied PECS block
versus general anesthesia during breast cancer surgery,
and they observed significantly lower VAS pain scores
in the PECS blocks group at all postoperative periods.
Conclusion
PECS block has more advantages in MRM. It
significantly reduces intraoperative fentanyl usage,
decreases postoperative pain, decreases the
requirement for postoperative supplemental analgesics,
and decreases the incidence of PONV. Moreover, under
ultrasonic guidance, it becomes a simple and easy-to-
learn technique, with relatively no complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

Regarding HR and MAP, there was a statistically References

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