The era of regional anaesthesia dates back to 1884 when Koller discovered the anesthesia properties of cocaine. Since then, the scope of regional anesthesia has continued to widen and clinicians have succeeded in gaining access to almost every nerve in the body. Consequently, patients who for one reason or another are considered unsuitable for general anesthesia may now have their operations done under regional anesthesia. Such was the situation with the two patients discussed in this report. Since the breasts are ectodermal organs, which arose as a modification of the sweat glands, they are more or less superficial structures, which can be isolated and selectively blocked for surgical excision. Combining intercostal nerves block with infraclavicular and midline subcutaneous infiltration with local anesthetic provided effective and reliable anesthesia for simple mastectomy in the two patients.
A 55-year-old postmenopausal woman presented with a four-month history of recurrence of a previously excised mass in the left breast. The mass had increased rapidly in size within two months prior to presentation. There was associated pain and left axillary swelling. She denied any history of nipple discharge, weight loss or cough. The mass was first noticed 16 months earlier, for which she had two previous excisions under local infiltration anesthesia in two different lower-level hospitals. The excised tissues were not subjected to histological examination. Physical examination revealed a middle-aged obese woman (weight 90 kg) in no apparent distress. Her pulse was 86 beats/min, regular, full volume and blood pressure was 130/80 mmHg. She had a radial scar over an approximately 6-cm-x-3-cm tumor mass on the upper inner quadrant of the left breast. The tumor was nontender but fixed to the chest wall over the fourth-through-sixth ribs and adjacent part of the sternum. There were few discrete mobile ipsilateral axillary lymph nodes enlargement. The chest was clear and there was no palpable hepatomegaly. Hematological and serum biochemistry results were essentially normal. Fine-needle aspiration cytology (FNAC) of the tumor mass and axillary nodes was positive for malignant cells. Radiological examination of the chest showed cannon-ball metastasis in both lung fields (Figure 1). Abdominal ultrasound scan was normal. A diagnosis of stage-IV carcinoma of the left breast with pulmonary metastasis was made. She was commenced on intravenous cyclophosphamide, methotrexate (arthritis) and 5-fluorouracil and oral tamoxifen. By the time she presented two weeks later, she had developed persistent unproductive cough, fever, dyspnea, tachypnea (respiratory rate 24 cycles/min) and tachycardia (pulse 102 beats/min). A repeat chest radiograph showed minimal pleural effusion on the right and fluid in the horizontal fissure of the right lung, in addition to the numerous malignant infiltrates in both lung fields (Figure 2). Hemograms showed PCV of 28% and WBC 11,800 mm. Following a course of generic antibiotics and therapeutic thoracocentesis instituted by the cardiothoracic surgical team, the patient’s condition improved and the hemograms normalized (PCV 32%, WBC 6,200 mm). There was, however, a progression of the tumor mass, as demonstrated by an increase in size to about 8 cm x 4 cm and worsening pain.
Figure 1. Chest x-ray of case 1 showing metastasis in both lung fields
After due consultation with the patient, a decision was taken to do palliative surgery (simple mastectomy) to prevent fungation of the mass and promote hygiene.
Figure 2. Repeat chest x-ray of case 1 showing right pleural effusion and metastasis in both lung fields
The decision to employ regional anesthesia for the surgery was jointly taken by the anesthetic and surgical teams because of the widespread malignant infiltration of both lungs. This was discussed with the patient. She consented to this anesthetic option with intraoperative sedation and conversion to general anesthesia if necessary. Don’t let the pharmacy companies beat you. Buy generic nexium online