Neoplasms

Skin and Connective Tissue Diseases

All Conditions

Breast Neoplasms

erector spinae block

retrolaminar block

serratus anterior block

pectoral nerve block

Walaa Y Elsabeeny, MD

Breast surgeries are common operative procedures that require appropriate postoperative analgesia.

Numerous pain relief techniques, including several new regional anesthesia techniques, are available for control of acute pain after breast surgery.

Locoregional Blocks for Breast Cancer Surgeries

time to first dose of rescue opioid analgesic

National Cancer Institute, Egypt

Assistant professor of Anesthesia, Surgical Critical care and Pain management

Central Nervous System Depressants

All Drugs and Chemicals

Ropivacaine

The Paravertebral Block is performed along the spine utilizing ultrasound guided technique (20-30 mL 0.5% Ropivacaine)

The Pectoral Nerve Block is performed anteriorly, at the level of the axillary line, also utilizing ultrasound guided technique (20-30 mL 0.5% Ropivacaine)

Paravertebral Block

Pectoral Nerve Block

Marianne Melink, MD

The purpose of this study is to compare two standard methods of pain control management used at Spectrum Health for patients undergoing breast surgery. The two methods being compared are the paravertebral block (PVB) and the pectoral nerve block (PEC). Postoperative pain control is essential following any major operative procedure. A variety of methods have been used to ensure adequate pain control, each with its own advantages and risks. Increasingly, attention has focused on regional methods of analgesia, which may allow for reduction in systemic narcotic use and their associated complications. Proposed benefits of regional analgesia and a resultant reduction in narcotic use include decreased risk of cancer progression, decreased length of stay, and decreased risk of ileus.

The purpose of this study is to compare the clinical profiles of two currently acceptable analgesia techniques. The most common regional block used to achieve postoperative analgesia following mastectomy is the paravertebral block, during which local anesthetic is injected into the paravertebral space which contains the thoracic spinal nerves, between the costotransverse ligament and the pleura. At our institution there has been recent interest in an alternative regional block. The pectoral nerve block is performed by injecting anesthetic between the pectoralis major and the pectoralis minor (PECs I) or between the pectoralis minor and the serratus anterior (PEC II).

The proposed advantage of the pectoral nerve block for regional anesthesia during breast surgery is equal analgesic efficacy with fewer potential complications.

Participants are randomized to one of two interventional arms (paravertebral block versus pectoral nerve block).

Paravertebral Block (PVC) Versus Pectoral Nerve Block (PEC)

Paravertebral Block Versus Pectoral Nerve Block for Analgesia Following Mastectomy

Participants for whom Narcotics were used for pain during surgery

Participants for whom Narcotics were used in PACU

Participants for whom Narcotics were used postoperatively

Measuring pain control by how long (in minutes) patient is in surgery

Measuring blood loss (in ml) during surgery

count of participants who reported nausea after surgery

Pain measured on scale of one to ten, one being least amount of pain and ten the greatest.

Participants who used narcotic pain pills postoperatively

Number of phone calls made to physician office regarding pain

Spectrum Health Hospitals

pain was not considered an adverse event unless it reached a grade 3 by CTCAE v4.0

The Paravertebral Block is performed along the spine utilizing ultrasound guided technique (20-30 mL 0.5% Ropivacaine)

Paravertebral Block: 20-30 mL 0.5% Ropivacaine

The Pectoral Nerve Block is performed anteriorly, at the level of the axillary line, also utilizing ultrasound guided technique (20-30 mL 0.5% Ropivacaine)

Pectoral Nerve Block: 20-30 mL 0.5% Ropivacaine

Total

Age, Continuous

Sex: Female, Male

Race (NIH/OMB)

United States

Region of Enrollment

Study was terminated early due to clinical practice outpacing the science of the trial. At the time of stopping enrollment, pectoral nerve blocks were being used standardly. Therefore, we could not ethically continue to randomize patients to both arms.

Marianne Melnik

Intraoperative Narcotic Use

Post Anesthesia Care Unit (PACU) Narcotic Use

Postoperative Narcotic Use

Pain Control Measured by Length of Operation

Pain Control Measured by Estimated Blood Loss

Paravertebral population had one non-reporting participant

Participants With Postoperative Nausea

Pain Control Measured by Pain Scale

Paravertebral Block arm had one participant with no response

Pain Control Measured by the Use of Pain Pills Postoperatively

one participant in each arm did not have a response recorded

Pain Control Measured by Calls to Physicians Office Relating to Pain

Overall Study

Symptoms and General Pathology

Nervous System Diseases

Pain, Postoperative

Pain

Postoperative Complications

Neurologic Manifestations

Analgesics

Bupivacaine

Narcotics

Group who was randomly selected to receive the intraoperative nerve block.

Patient who was randomly selected not to receive intraoperative nerve block

Patients who were given 20 cc of 0.25% Marcaine as part of the pectoralis nerve block

Patient's underwent indicated procedure without regional pectoralis nerve block

Surgery without Nerve Block

Kaitlyn Kennard, MD

Robin Ciocca, MD

Jennifer Sabol, MD

Ned Carp, MD

The aim of this study is to evaluate patients who are undergoing partial mastectomy or removal of breast tissue and see if a pectoralis nerve block (PECS) can provide a meaningful improvement in postoperative pain control over standard pain medication. The hope is that this will decrease the need for postoperative narcotics. Prior studies have shown improved pain control using a PECS block in patients who undergo a mastectomy. PECS block is a procedure in which local anesthesia, similar to that used by dentists, is injected in the muscles of your chest and arm pit during your surgical procedure while you are asleep. This anesthetizes the nerves in the area which decreases pain. The local anesthetic used is called Marcaine. Marcaine is the brand name for bupivacaine hydrochloride which is an anesthetic known for its long duration in comparison to lidocaine.

It is known that postoperative pain is a risk factor for chronic pain which is tied to increased narcotic use. Due to the opioid epidemic considerable time and research has gone into decreasing opioid use particularly in post-operative period. The PECS block procedure involves injecting local anesthesia between two chest muscles called pectoralis major and pectoralis minor. There is an additional injection between the pectoralis minor and serratus anterior which is another muscle of the chest.

This study will be conducted at Lankenau Medical Center of Main Line Health. You have been selected since you will be undergoing a partial mastectomy (removal of a part of your breast). It is believed that PECS block has the potential to benefit your postoperative pain control. A total of 130 patients will be recruited and 65 will be placed into the treatment arm (receive intraoperative nerve block) and 65 will be placed into the non- treatment arm (no nerve block) for comparison.

Prior investigations have shown that use of intraoperative PECS blocks in patients undergoing a Modified Radical Mastectomy improves postoperative pain control and decreases postoperative narcotic use which will eventually mitigate the issue of dependence on narcotics postoperatively (Kulhari et al, Blanco et al). The aim of this study is to do a prospective randomized control of patients undergoing a Partial Mastectomy at Lankenau Medical Center to see if pectoral nerve block (PECS) provides a meaningful improvement in postoperative pain control over standard pain medication as well as a decrease in postoperative narcotic use.

PECS block as described by Blanco et al has been used safely and effectively used for modified radical mastectomy in multiple studies as reviewed above (Blanco et al, Kumar et al, Kulhari et al). The breast surgeons at Lankenau Medical Center within Main Line Health are currently using the PECS block as part of their partial mastectomy procedure and have been since 5/1/19. The PECS block is currently being used at random when time and resources allow There are not certain subsets or patients who are selected for this procedure. This procedure has been well tolerated by patients and has proved feasible for the surgeons and surgical team to facilitate. Therefore since PECS block for partial mastectomy are within the standard of care at Lankenau Medical Center this study only introduces a risk of randomization rather than the increased risk of the procedure itself.

This is a randomized prospective control study looking at patients at Lankenau Hospital undergoing partial mastectomy from 8/30/19- 8/30/20 after obtaining Institutional Review Board (IRB) approval. The plan is to recruit 130 patients with 65 patients randomized into each cohort. One cohort will receive the PECS II block intraoperatively and one cohort will not. This will be a single blinded randomized control trial in that the surgeon knows who will be receiving the block however the patient will be blinded. Patient must be able to provide their own consent to be included in this study. There will be no advertisement or compensation for this study. The study will be explained to the eligible candidates at time of discussion of their surgery. Patients will be informed that involvement in the study does not affect their ability to seek or receive care at this facility.

A written informed consent will be obtained from all patients. The patients once scheduled for surgery unit will be enrolled in research study by an independent research assistant. The participants will be allocated randomly into two groups according to block randomization schedule shown below. Group one will receive anesthesia only and Group two will receive anesthesia and PECS block. The surgeon who will be performing the intraoperative block will be informed of the random and independent assignment prior to surgery. The patients will be instructed on usage of a 10-mm Visual Analogue Scale (VAS) for pain graded from 0 (no pain) to 10 (most severe pain) before surgery. Patients will be blinded as to whether or not they will be receiving intraoperative PECS block. In both the control and test groups, patients will receive general anesthesia with laryngeal mask airway or endotracheal tube per anesthesiologist discretion. Induction of anesthesia will use fentanyl 1 μg/kg and propofol 1.5-2 mg/kg until loss of verbal response with or without muscle relaxant as needed. Maintenance of anesthesia will be assessed for any intraoperative rise in heart rate and systolic blood pressure more than 20% from pre-induction value. If this occurs fentanyl 0.25 μg/kg can be administered IV. Toradol should be given unless contraindication at the end of the case. No ketamine or dilaudid will be used. Long acting opioids will be avoided. Once anesthesia is instituted prior to prepping and draping a timeout will be called during which patient will be identified and procedures to be performed will be identified.

Procedures The patient will be kept in supine position with ipsilateral arm in abducted position. The skin overlying the ipsilateral breast and adjoining infraclavicular and axillary regions will be disinfected with chloraprep and sterile draping of the area is performed. A linear ultrasound probe of high frequency (6-13 MHz) of a portable ultrasound system (Sonosite, Micromaxx Bothell, Washington USA) is taken. The probe will be covered with a sterile transparent dressing and a sterile conductivity gel will be applied. The imaging depth on the ultrasound screen is set to 4-6 cm. The ultrasound probe will first be placed cephalocaudally in the infraclavicular region and moved laterally to locate vessels directly above the 1st rib. With further lateral and downward movements the 3rd and 4th ribs will be identified. The probe is maneuvered and appropriate anatomical structures including pectoralis major and minor muscles and serratus anterior muscle are identified.

The interface between pectoralis major, pectoralis minor and serratus anterior are identified. A spinal needle 20 gauge and 4 inches in length will be used to instill 10 cc of 0.2% Marcaine between serratus anterior and pectoralis minor. Aspiration is continuously used to confirm that there is no intravenous or intra-arterial injection of local anesthesia. The needle will then be withdrawn slightly, and 10 cc of 0.25% Marcaine is injected between pectoralis major and pectoralis minor under direct ultrasound visualization. Attention is then turned to the axilla of the operative side. A spinal needle under direct visualization is used to deliver 10 cc of 0.25% Marcaine between latissimus dorsi and serratus anterior. The PECS block is finished, and the rest of the procedure is performed according to surgeon discretion. All patients whether or not they receive the PECS block will receive 10 cc of 0.25% Marcaine subcutaneously at incision site.

Single blinded randomized control trial in which patient was unaware of treatment arm

PECS Block in Partial Mastectomy for Postoperative Pain Control

Use of PECS Block in Partial Mastectomy for Postoperative Pain Control and Mitigation of Narcotic Use- A Randomized Control Trial

Visual Analogue Pain scores scaled from 1-10 with 1 being no pain and 10 being worst pain of one's life. This scale is used to assess postoperative pain. Scores will be compared between the two groups.

Amount of pain medication in morphine equivalents used after surgery until day 3

Main Line Health

Post Doctoral Research Fellow

Gland and Hormone Related Diseases

Thyroid Diseases

Thyroid Neoplasms

Endocrine Gland Neoplasms

Head and Neck Neoplasms

Endocrine System Diseases

Anesthetics

An ultrasound probe was placed obliquely over the second and third ribs below the lateral one-third of the clavicle. After identification of the anatomical structures, the needle was advanced along a superior-medial-to-inferior-lateral passage to the tissue plane between the pectoralis minor and serratus anterior muscles, and 20 mL ropivacaine (0.375% w/v) was injected at the level of the third rib. The anesthetic spread around the axilla, and the needle was withdrawn to the point in the plane between the pectoralis major and minor muscles. A second injection of 20 mL ropivacaine (0.375% w/v) was then delivered (PECS II).

Pectoral nerve block

Min Suk Chae, MD, PhD

Kwangsoon Kim, MD, PhD

The da Vinci robotic system was developed to improve both operative maneuverability (through multi-articulated instruments) and the surgical view (via a three-dimensional camera). Although the system has many advantages, skin incision, wide flap dissection, and pneumatic/mechanical retraction remain essential, but cause postoperative pain and slower recovery. Previous studies found that pectoralis fascial blocks were easy to establish; local anesthetics are injected between two adjacent myofascial layers under ultrasound guidance, providing the surgeon with a clear image. Analgesic efficacy has been validated during robotic thyroidectomy in our institution. The pain outcomes were comparable between the groups, but there were fewer complications in the PECS II group. The investigators investigated whether this block can reduce postoperative pain during wide flap dissection for single-port robot-assisted transaxillary thyroidectomy.

PECS II Block and Single Port Robot-assisted Transaxillary Thyroidectomy

Study on the PECS II Block With Postoperative Pain in Patients Undergoing Single Port Robot-assisted Transaxillary Thyroidectomy: Double-blinded Randomized Controlled Trial

Visual analog scale from 0 (minimum) to 10 (maximum)

The Korean version of QoR-15 (QoR-15K questionnaire) from 0 (minimum) to 150 (maximum)

Min Suk Chae

Assistant professor

Anti-Arrhythmia Agents

Channel Blockers

Lidocaine

Analgesics, Opioid

Anesthetics, Local

Sodium Channel Blockers

Diuretics, Potassium Sparing

Interventions: include pain assessment, inflammatory response and opioid consumption.

Patients could be submitted to general anesthesia or general anesthesia associated with SAM and PEC I block with lidocaine before mastectomy.

Interventions: include pain assessment, inflammatory response and opioid consumption.

Block with lidocaine for SAM and PEC I block

Luiz Fernando Reis, PhD

The serratus anterior muscle plane (SAM) block associated with pectoral nerve block type I (PEC I) may be a safe and effective alternative for the intraoperative of breast surgery, since there is evidence of pain reduction. However, correlation between regional anesthesia, postoperative pain and inflammatory response in breast surgery has not been demonstrated. The aim of this study is to compare the standard intravenous analgesia versus systemic analgesia associated with the SAM block and PEC I during breath cancer surgery. The following parameters will be evaluated: consumption of opioid intra and post-operative; post-operative pain and release of plasma inflammatory cytokines. It is a clinical prospective, randomized and controlled study. 50 individuals will be randomly divided into two groups. A group of patients receive general anesthesia during surgery and intravenous analgesia after the surgery and another group will receive general anesthesia associated with SAM and PEC I block during intraoperative and postoperative systemic analgesia. The postoperative pain will be assessed using the Visual Analogue Scale pain in the recovery room and 24 hours after surgery. Blood sample will be collected for determination of serum cytokines before surgery and 24 hours after the surgery. Also, it will be evaluated the development of chronic neuropathic pain 12 months after mastectomy, the use of analgesic medication, quality of life, depressive symptoms, and the levels of interleukin (IL)-1 beta, IL-6, and IL-10 as predictors of pain and depression.

In breast surgery, regional anesthesia associated with general anesthesia during surgery has shown great results for the post-operative pain management, prevention of tumor recurrence and development of neuropathic pain. It has been shown that regional anesthesia attenuates the inflammatory response and systemic changes postoperatively during breast surgeries. Thus, it is important to include an additional analgesic intervention in breast surgery in order to decrease the local inflammatory response and the postoperative pain. Thus, the serratus anterior muscle plane (SAM) block associated with pectoral nerve block type I (PEC I) may be a safe and effective alternative for the intraoperative of breast surgery, since there is evidence of pain reduction. However, correlation between regional anesthesia, postoperative pain and inflammatory response in breast surgery has not been demonstrated. The aim of this study is to compare the standard intravenous analgesia versus systemic analgesia associated with the SAM block and PEC I during breath cancer surgery. The following parameters will be evaluated: consumption of opioid intra and post-operative; post-operative pain and release of plasma inflammatory cytokines. It is a clinical prospective, randomized and controlled study. Also, it will be evaluated the development of chronic neuropathic pain 12 months after mastectomy, the use of analgesic medication, quality of life, depressive symptoms, and the levels of interleukin (IL)-1 beta, IL-6, and IL-10 as predictors of pain and depression. 50 individuals will be randomly divided into two groups. A group of patients receive general anesthesia during surgery and intravenous analgesia after the surgery and another group will receive general anesthesia associated with SAM and PEC I block during intraoperative and postoperative systemic analgesia. The postoperative pain will be assessed using the Visual Analogue Scale pain in the recovery room and 24 hours after surgery. Blood sample will be collected for determination of serum cytokines before surgery and 24 hours after the surgery.

Pain Control in Breast Surgery: Analgesia, Opioid Consumption and Inflammatory Response Evaluation

The postoperative pain will be assessed using the Visual Analogue Scale pain in the recovery room and 24 hours after surgery.

The opioid consumption will be evaluated during and 24h after breast surgery

Blood sample will be collected for determination of serum cytokines before surgery and 24 hours after the surgery.

The development of chronic pain 12 months after mastectomy will be evaluated using the following scales: Douleur Neuropathique-4 - DN-4 (scores 4 or more indicates neuropathic character), Numeric Rating Scale - NRS ranging from 0 (no pain) -10 (worst pain) and Short-Form Health Survey (SF-36) ranging from zero (worst) to 100 (best score).

Hospital Sirio-Libanes

MS, PhD

Breast Diseases

Fibroadenoma

Skin Diseases

Neoplasms, Fibrous Tissue

Neoplasms, Connective Tissue

Neoplasms, Connective and Soft Tissue

Neoplasms by Histologic Type

Neoplasms, Glandular and Epithelial

Adjuvants, Anesthesia

Anti-Inflammatory Agents

Antirheumatic Agents

Fentanyl

Ibuprofen

In group P, PECS will be performed with patients in the supine position at the end of the surgery before extubation by using US (Vivid Q, GE Healthcare, US). Under aseptic conditions the high frequency linear probe (11-12 MHz) will be covered with a sterile sheath and a 22G, 50 mm block needle will be used. US probe will be placed on the 4th rib. The muscles PMm, Pmm and Sam will be visualized. At the anterior axillary level or mid-axillary level, via the in-plane technique, Pecs II will be applied by injecting 20 mL of 0.25% bupivacaine in a cephalad to caudad direction to the fascia on Sam.

In group R, RIB block will be performed with patients in the lateral decubitus position at the end of the surgery before extubation. The linear high frequency probe will be placed in sagittal plane medially on the medial border of the scapula at T5-6 level. The trapezius muscle, rhomboid major muscle, intercostal muscle, ribs and the pleura will be visualized. The needle will be inserted into the fascial plane between the rhomboid major and intercostal muscles in a cranio-caudal direction. A dose of 20 ml 0,25% bupivacaine will be injectted into the fascial plane.

A dose of ibuprofen 400 mgr and tramodol 100 mg will be performed intraoperatively. Patients will be administered ibuprofen 400 mgr IV every 8 hours in the postoperative period. A patient controlled device prepared with 10 mcg/ ml fentanyl will be attached to all patients with a protocol included 10 mcg bolus without infusion dose, 10 min lockout time and 4 hour limit.

PECS block

Rhomboid intercostal block

Postoperative pain is an important issue in patients underwent mastectomy and axillary dissection surgery. Postoperative effective pain treatment provides early mobilization and shorter hospital stay. The US-guided pectoral nerve block (PECS) may be used for postoperative pain treatment following breast surgery. It is a novel interfascial block that was defined by Blanco. Rhomboid intercostal block (RIB) is a novel block and was first described by Elsharkawy et al. Local anesthetic solution is administrated between the rhomboid muscle and intercostal muscles over the T5-6 ribs. It has been reported that RIB may provide effective analgesia management for several breast surgeries.

The primary aim of the study is to compare postoperative opioid consumption and the secondary aim is to evaluate postoperative pain scores (VAS), adverse effects related with opioids (allergic reaction, nausea, vomiting).

Postoperative pain is an important issue in patients underwent mastectomy and axillary dissection surgery. Postoperative effective pain treatment provides early mobilization and shorter hospital stay, thus complications due to hospitalization such as infection and thromboembolism may be reduced.

Various methods may be performed to reduce the use of systemic opioids and for effective pain treatment following mastectomy and axillary dissection surgery. Ultrasound (US)-guided interfascial plane blocks have been used increasingly due to the advantages of ultrasound in anesthesia practice. The US-guided pectoral nerve block (PECS) may be used for postoperative pain treatment following breast surgery. It is a novel interfascial block that was defined by Blanco. It is easy to perform; under ultrasound (US) guidance, the interfascial region between the pectoral muscles (pectoralis major (PMm) and minor (Pmm), serratus anterior Sam) is injected with local anaesthetics. It has been reported that PECS type-2 block provides effective analgesia management for mastectomy and axillary dissection surgeries.

Rhomboid intercostal block (RIB) is a novel block and was first described by Elsharkawy et al. Local anesthetic solution is administrated between the rhomboid muscle and intercostal muscles over the T5-6 ribs 2-3 cm medially of the medial border of the scapula. RIB targets both the posterior rami and lateral cutaneous branches of the thoracic nerves and provides analgesia for the hemithorax from T2 to T9. It has been reported that RIB may provide effective analgesia management for several breast surgeries.

The aim of this study is to evaluate the efficacy of the US-guided PECS-II and RIB for postoperative analgesia management compare to no intervention control group after mastectomy and axillary dissection surgery. The primary aim is to compare postoperative opioid consumption and the secondary aim is to evaluate postoperative pain scores (VAS), adverse effects related with opioids (allergic reaction, nausea, vomiting).

There are three models for this study. Patients will be randomly divided into three groups (Group P = PECS group, Group R = RIB group, Group C = Control group), before entering the operating room.

The anesthesiologist who performs postoperative pain evaluation will not know the group.

Pectoral Nerve Block Type-II and Rhomboid Intercostal Block for Pain Management Following Mastectomy Surgery

Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Mastectomy Surgery

The primary aim is to compare postoperative opioid consumption

Postoperative pain assessment will be performed using the VAS score (0 = no pain, 10 = the most severe pain felt). The VAS scores will be recorded

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Locoregional Blocks for Breast Cancer Surgeries	NCT06230575	Analgesia	erector spinae ... retrolaminar bl... serratus anteri... pectoral nerve ...	18 Years - 65 Years	National Cancer Institute, Egypt
Paravertebral Block (PVC) Versus Pectoral Nerve Block (PEC)	NCT03152929	Breast Cancer	Paravertebral B... Pectoral Nerve ...	18 Years -	Spectrum Health Hospitals
PECS Block in Partial Mastectomy for Postoperative Pain Control	NCT04086394	Breast Cancer Postoperative P... Opioid Use Local Anesthesi...	Pectoral Nerve ... Surgery without...	18 Years -	Main Line Health
PECS II Block and Single Port Robot-assisted Transaxillary Thyroidectomy	NCT06101043	Thyroid Cancer	Pectoral nerve ...	19 Years - 60 Years	Seoul St. Mary's Hospital
Paravertebral Block (PVC) Versus Pectoral Nerve Block (PEC)	NCT03152929	Breast Cancer	Paravertebral B... Pectoral Nerve ...	18 Years -	Spectrum Health Hospitals
PECS II Block and Single Port Robot-assisted Transaxillary Thyroidectomy	NCT06101043	Thyroid Cancer	Pectoral nerve ...	19 Years - 60 Years	Seoul St. Mary's Hospital
Pain Control in Breast Surgery: Analgesia, Opioid Consumption and Inflammatory Response Evaluation	NCT02647385	Breast Cancer Anesthesia	Block with lido...	18 Years - 75 Years	Hospital Sirio-Libanes
Paravertebral Block (PVC) Versus Pectoral Nerve Block (PEC)	NCT03152929	Breast Cancer	Paravertebral B... Pectoral Nerve ...	18 Years -	Spectrum Health Hospitals
Pectoral Nerve Block Type-II and Rhomboid Intercostal Block for Pain Management Following Mastectomy Surgery	NCT04297007	Breast Cancer Breast Neoplasm... Breast Diseases Breast Fibroade...	PECS block Rhomboid interc...	18 Years - 65 Years	Medipol University
PECS Block in Partial Mastectomy for Postoperative Pain Control	NCT04086394	Breast Cancer Postoperative P... Opioid Use Local Anesthesi...	Pectoral Nerve ... Surgery without...	18 Years -	Main Line Health

Spots Global Cancer Trial Database for pectoral nerve block