The effect of opioid free versus opioid based anaesthesia on breast cancer pain score and immune response

Abstract

Background: Modified radical mastectomy (MRM) with axillary clearance of lymph nodes was routinely performed under general anaesthesia with intra-and postoperative opioid analgesia. Recently, there has been a move toward opioid-free anesthesia (OFA) to appreciate the goals of hypnosis with amnesia and sympathetic stability without the adverse effects of opioids.The aim of this study was to evaluate the effect of OFA versus opioid-based anaesthesia (OBA) in patients with breast cancer, who had undergone unilateral MRM. The primary aims:• Pain intensity using the visual analogue scale in the first 24 h post-operatively.• Screening for post mastectomy neuropathic pain. The secondary aims:• Effect of opioid and surgical stress on the immune system.• Patient outcome including haemodynamic stability, patient satisfaction and occurrence of post-operative complications. Methods: Forty adult female patients scheduled for elective unilateral MRM were randomly divided into two groups (20 patients in each group): OFA and OBA. Results: There was statistically significant decrease in pain score at rest and on movement in the OFA group. Postoperative nausea and vomiting was significantly decreased in the OFA group (P = 0.04). Patients in the OFA group were more satisfied than those in the OBA group using verbal rating scale for satisfaction (P < 0.001). There was significant low incidence of neuropathic pain in the OFA group; also, we found significant changes in interleukin 10, tumour necrosis factor alpha and caspase 3 between the two groups. Conclusion: OFA is safe and effective in mastectomy as it decreases the pain score and the incidence of post mastectomy neuropathic pain; moreover, it also shows better immune response postoperatively.

The efficacy and safety of an adapted opioid-free anesthesia regimen versus conventional general anesthesia in gynecological surgery for low-resource settings: a randomized pilot study

“…We attribute this finding to the lack of opioids in the OFA group which have a respiratory depressing property compared to ketamine used in the adapted OFA protocol which has a bronchodilator effect and no respiratory depression effect [ 49 ]. This observation corroborates with those of previous clinical trials by El-dein Aboalsoud et al [ 31 ]. on modified radical mastectomy with axillary for breast cancer surgery.…”

“…It is worth mentioning that despite our relatively small sample size statistically significant differences in pain scores were still observed at 12 h and 24 h post-operation mainly in patients who underwent mastectomy considering the severity in pain intensity of the latter. This finding of statistically significant differences in pain intensity at 12 h and 24 h post-operation concurs with those of Di Benedetto P et al [ 40 ], Tripathy S et al [ 28 ] and El-dein Aboalsoud RAH et al [ 31 ] on OFA vs. CGA for mastectomy in breast cancer with a similarly healthy ASA I and II small-sample population. In the same vein, the advantage of ketamine in procuring intra-operative and postoperative analgesia in OFA needs to particularly be spelled out.…”

“…We found this adapted OFA protocol had a 100% success rate with significant lesser consumption of isoflurane, no significant intraoperative complication and better intraoperative hemodynamic stability in the OFA group. These findings re-iterate previous reports from other clinical trials on gynecological surgery [ 26 , 28 – 31 , 35 – 41 ] demonstrating a 100% success rate for OFA with stable or better hemodynamics and no intra-operative complications. By contrast, a multicentre French clinical trial on 314 non-cardiac surgeries (with 5.7% gynecological surgical procedures) reported more hypertension, hypotension and severe bradycardia (less than 45 beats/min) during OFA which prompted the early termination of the clinical trial [ 25 ].…”

“…This was an expected finding that has been correlated with the pharmacodynamic properties of opioids on the intestines: a reduction of peristaltic movements [ 8 ]. Similar to other authors working on both abdominal and laparoscopic gynecological surgery [ 29 , 30 , 37 , 38 ] as well as mastectomy [ 28 , 31 ] patients in the OFA group demonstrated statistically significant quicker postoperative mobilization or recovery with better postoperative satisfaction assessed on either the QoR-40 questionnaire or verbal rating scale for satisfaction. This reinforces evidence of OFA as being safe and effective for gynecological surgery.…”

“…Two other large well-powered recent studies [26,27] conducted in highincome settings, comparing OFA (using dexmedetomidine) to CGA in laparoscopic gynecological surgery showed equivalent postoperative pain, postoperative opioid consumption, PONV, anti-emetic requirements [26,27] with even more significant sedation scores and longer PACU LOS in the OFA group [27]. On the other hand, studies [28][29][30][31] carried out in low-and middle-income countries above the Saharan region with some using dexmedetomidine in OFA for gynecological surgery are in favour of better hemodynamic stability in addition to the aforementioned benefits of OFA. With an extensive literature search, to the best of our knowledge, there is a dearth of comprehensive or reference data on the feasibility, safety and effectiveness of OFA in gynecological surgery in sub-Saharan Africa, the most poverty stricken region of the world and where dexmedetomidine is not available due to its relatively high financial cost.…”