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Thoracodorsal Artery Perforator Flap Following Partial Mastectomy: A Randomized Controlled Trial 菱形肋间神经阻滞与前锯肌前平面阻滞用于乳房部分切除术后胸背动脉穿支皮瓣术后镇痛的随机对照试验 论文摘要 Background:The thoracodorsal artery perforator (TDAP) flap has been developed to improve the postoperative aesthetic and psychological states of patients who receive breast-conserving surgery (BCS); nonetheless, the TDAP flap exacerbates the pain that occurs at 2 surgical sites. 背景:胸背动脉穿支(TDAP)皮瓣已被开发用于改善接受保乳手术(BCS)患者的术后美学和心理状态；然而，TDAP皮瓣加重了两个手术部位的疼痛。 Objectives:This trial aimed to compare the efficacy of the rhomboid intercostal block (RIB) and the serratus anterior plane block (SAB) as postoperative analgesics for BCS. 目的:本试验旨在比较菱形肋间阻滞(RIB)和前锯肌平面阻滞(SAB)作为BCS术后镇痛的效果。 Study design:Prospective randomized controlled clinical trial. 研究设计:前瞻性随机对照临床试验。 Setting:This clinical trial was conducted at Zagazig University Hospitals. 环境:该临床试验在Zagazig大学附属医院进行。 Methods:Eighty-four patients scheduled for BCS followed by a TDAP flap were randomly divided into 3 groups (of 28 patients each). Group C received general anesthesia, and groups SAB and RIB received SAB and RIB blocks, respectively, followed by general anesthesia. The cumulative tramadol consumption within 24 hours after the operation was the primary outcome. The postoperative pain score, first-rescue analgesic time, and sensory block coverage were the secondary outcomes. 方法:84例拟行BCS和TDAP皮瓣转移的患者随机分为3组，每组28例。C组接受全身麻醉，SAB组和RIB组分别接受SAB和RIB阻滞，然后进行全身麻醉。术后24小时内曲马多的累积消耗量是主要结果。术后疼痛评分、首次急救止痛时间和感觉阻滞覆盖率是次要结果。 Results:The 24-hour cumulative tramadol consumption and duration of the first rescue analgesic were significantly lower and longer, respectively, in the RIB group, than in the SAB group or the control group. The VAS score was lower in the RIB group than in the SAB or control group at all measurement times, except at 24 hours postoperatively, and the values among the groups were not significantly different. Dermatomal coverage of the anterior and posterior hemithorax extended from T2-T9 in the RIB group and from T2-T10 in the anterior hemithorax only in the SAB group. 结果:与SAB组或对照组相比，RIB组的24小时累积曲马多消耗量和首次抢救镇痛药的持续时间分别显著降低和延长。除术后24小时外，RIB组的VAS评分在所有测量时间都低于SAB组或对照组，并且各组之间的数值没有显著差异。在RIB组中，前后半胸的皮区覆盖从T2-T9延伸，而在SAB组中，仅在前半胸的皮区覆盖从T2-T10延伸。 Limitations:Both block procedures were applied as single shots, and their impact on chronic postoperative pain was not assessed; the observation may therefore be drawn that a continuous local anesthetic (LA) infusion catheter could be used to extend the period of analgesia. 局限性:两种阻滞方法都是单次注射，并且没有评估它们对慢性术后疼痛的影响；因此，可以观察到持续局部麻醉(LA)输注导管可用于延长镇痛期。 Conclusion:Because of its ability to block both the anterior and posterior hemithorax, the RIB, is more efficient than the SAB at controlling acute pain and reducing opioid consumption in patients undergoing BCS followed by TDAP flaps; thus, the RIB can be employed as a potential alternative in these surgeries. 结论:由于其阻断前后半胸的能力，菱形肋间阻滞比前锯肌平面阻滞更能有效地控制保乳手术术后胸背动脉穿支皮瓣患者的急性疼痛和减少阿片类药物的消耗；因此，菱形肋间阻滞可以在这些手术中用作潜在的替代物。 主要结果 1.技术图像  (A) 深前锯肌平面阻滞的超声图像。(B)菱形肋间阻滞的超声图像。LDM:背阔肌，ICM:肋间肌，LA:局麻药；白色箭头表示锯肌、肋间肌和肋骨之间(A)或菱形肌和肋间肌和肋骨之间(B)的局部麻醉剂扩散。 2.手术技术图 A. 肿瘤切除；b组:切取胸背穿支皮瓣；c组:术后皮瓣修复缺损；d:皮瓣供区瘢痕。 3.The time to perform the block was significantly shorter (P < 0.001) in the SAB group than in the RIB group .SAB组实施阻滞的时间显著短于RIB组(P < 0.001) 4.Regarding total tramadol consumption at 24 hours after the operation, there was a statistically significant difference among the 3 studied groups: the highest doses were in the control group, followed by the SAB group, while the lowest doses were observed in the RIB group. 关于术后24小时的曲马多总消耗量，3个研究组之间存在统计学显著差异:对照组的剂量最高，其次是SAB组，而RIB组的剂量最低  4.As for the first use of rescue analgesia and intraoperative fentanyl, there were significantly shorter treatment times and higher doses, respectively, in the control group, followed by the SAB group, with the RIB group experiencing the longest treatment time and lowest doses by significant margins (Table 2). However, as far as complications were concerned, there was no significant difference in the incidence of nausea and vomiting among the 3 studied groups or in LA toxicity and needle trauma between the 2 interventional groups (Table 2). 至于第一次使用抢救性镇痛和术中芬太尼，对照组的治疗时间明显更短，剂量明显更高，其次是SAB组，RIB组的治疗时间最长，剂量明显最低(表2)。然而，就并发症而言，3个研究组之间的恶心和呕吐发生率或2个干预组之间的LA毒性和针刺伤没有显著差异 5.There was a highly statistically significant difference in the VAS score at rest or with movement among the 3 studied groups: the highest values at the PACU and at one, 3, 6, and 12 hours postoperatively were observed in the control group (P ≤ 0.001), followed by the SAB group, while the RIB group had the lowest significant values at rest at one, 3, 6, and 12 hours postoperatively (P ≤ 0.001) and with movement at 3, 6, and 12 hours postoperatively (P ≤ 0.001); however, at 24 hours postoperatively, there was no significant difference among the 3 studied groups (P = 0.594 at rest, P = 0.132 with movement) (Fig. 5). 三个研究组之间在静息或运动时的VAS评分存在高度统计学显著性差异:对照组在PACU和术后1、3、6和12小时观察到最高值(P ≤ 0.001)，其次是SAB组，而RIB组在术后1、3、6和12小时静息时(P ≤ 0.001)和术后3、6和12小时运动时具有最低显著性值(P≤0.001)；然而，在术后24小时，3个研究组之间没有显著差异(休息时P = 0.594，运动时P = 0.132)(图5)。  6.总结思考 本试验评估了保乳术后TDAP皮瓣部分乳房重建术后菱形肋间阻滞和前锯肌平面阻滞的镇痛效果，并显示组在术后24小时内的曲马多消耗量低于前锯肌平面阻滞组或者对照组。此外，菱形肋间阻滞组在静息和PACU活动时以及术后12小时内表现出更长的首次抢救镇痛时间和更低的VAS评分。然而，在阿片类或阻滞相关的并发症方面，试验组之间没有发现差异。尽管两种阻滞方式在术后镇痛中，都变现出良好的镇痛效果，但都是单次注射，并且没有评估它们对慢性术后疼痛的影响；因此，可以在后续临床中继续观察持续阻滞是否可以延长镇痛期，获得更少的镇痛药物需求。 文献精读/差劲先森。 排版/肉肉 【🔍关注我们，掌握国际前沿医疗动态！】 （点击关注，获取更多医疗干货！💌） |
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