Breast cancer is a serious disease that can sometimes only be managed operatively with a mastectomy. A percentage of patients opt to have an immediate reconstruction performed at the same time. The postoperative management of these patients greatly affects both the cosmetic and psychological outcome of the surgery.

The National Mastectomy and Breast Reconstruction Audit was one the most important audits in recent times, that looked at outcomes of surgery, and particularly at what is known as “patient reported outcomes” (PROMS). These were gathered by questionnaires at three and 18 months, gaining new insights into the patient experience following breast cancer surgery. Within these outcomes it was found that 8% of patients remained in pain most or all of the time after immediate reconstruction and 9% after delayed breast reconstruction.

Although small in percentage terms, chronic pain represents a devastating effect on these women’s lives and improving early pain control may have a big impact on long-term outcomes. Over the last 2 years I have been working closely to audit pain control in my practice, and develop and refine preoperative, perioperative and postoperative strategies to improve my patient’s outcomes.

Traditionally there has been no formal pathway in place for post-operative analgesia in breast patients. Prescribing practices in these patients was audited, and an array of analgesics were given to patients.

Following experience of a single surgeon/single anaesthetist approach in complex breast surgical patients with good pain outcomes, a standardised approach has been taken to develop a pathway to optimally manage pain in breast surgery patients, in my practice. 

The use of surgical drains following breast surgery

Vacuum drains are inserted into the breast after surgery to allow blood and tissue fluid a conduit out of the wound. This initially aids wound healing and helps prevent the later formation of a seroma. They also allow the surgical team to be aware of any problems with wound bleeding, sometimes requiring a short further operative procedure to control. The drains come out through the skin and it is this site that is often a source of significant pain and local tenderness.

However, leaving drains in for too long poses a risk of infection. The suction of the vacuum actually increased wound fluid output, delaying the healing process and delaying discharge.

The policy in my hospital was for a patient to have a drain removed if the output was less than 100ml within 24 hours. This leads to inpatient stays of two to three days on average, with some staying for up to five days. This policy has been audited and found to have little impact on fluid collecting under the skin (seroma) formation, and likely increases infection risk. 

The principles of pain management in my breast cancer surgical practice is based on the use of:

A: Multimodal analgesia

At induction:

  • Dexamethasone as antiemetic
  • Paracetamol IV as analgesic
  • Low dose ketamine acting on NMDA receptors as analgesic
  • High dose fentanyl acting on opiate receptors as analgesic
  • Intramuscular morphine acting as depot analgesic

Intraoperative:

Measurement of entropy allowing titration of propofol-based analgesia and top- up doses of fentanyl ketorolac in suitable patients (also an evidence base for cancer benefit).

B: High volume – Low dose infiltration analgesia

The use of large volumes of chirocaine local anaesthetic combined with clonidine (alpha 2 agonist effect) and adrenaline allows good infiltration coverage of drain sites where most pain is often centered, but also large doses with longer duration of action with the addition of adrenaline.

New policy

Following the outcome of both of these initial audits new policies has been put into effect.

Drains

Two vacuum drains will be inserted intra-operatively.

The contents of these drains will be measured at six hours post-op. If the volume is less than 150ml in total the drains can be removed at that time.

If greater than 150ml the drains will remain in-situ and will be reviewed at 8am on day one post-op. If the total volume at eight am, day one is less than 250ml, the drains can be removed and the patient discharged. If the total volume exceeds 250ml, the patient can be discharged with a single drain to be removed at post-op clinic day between day size and 10. If the patient requires a change of drain bottle the procedure is to speak with the ward directly and request a change of drain bottle.

For patients undergoing LD flap-based reconstruction, drain management will be individualized and not be protocol-driven.