Combined pectoralis II block and transversus thoracic plane block compared to erector spinae plane block for post-operative analgesia in patients undergoing modified radical mastectomy: A randomized clinical trial

Background: About 30% of Egyptian females had breast cancer. Surgery is a cornerstone of the treatment plan. New fascial plane block techniques enhance recovery and improve intra-operative and post-operative pain control.Aim of the study: Effect of combined pectoralis II plus transversus thoracic plane blocks (PECS II- TTP) versus erector spinae plane block (ESPB) on post-operative morphine consumption, and interleukin-6 (IL-6) levels 24 hours after surgery.Methods: Sixty-four female patients 18-60 years of age, ASA I or II were divided into two equal groups (32 patients each). Group (P) received a combination of PECS II and TTP blocks (injection of 10 ml 0.25% bupivacaine between pectoralis major (PM) and minor (Pm) muscles and 10 ml between the Pm and serratus anterior (Sa) muscles) at the third or the fourth rib, then 10 ml and the internal inter-costal muscles and the transversus thoracic muscle. Group (E) received ESPB (30 ml of 0.25% bupivacaine injected deep to the erector spinae muscle at the transverse process of the fifth thoracic vertebrae).Results: Morphine consumption was significantly lower in group (E) throughout the 24 hours period of post-operative follow-up (0.93 +/- 0.63 vs. 2.13 +/- 0.42 (mg); p = 0.03). Both groups had comparable time till the first analgesic request (p = 0.23). There was statistically non-significant difference between the two groups regarding the numeric rating scale (NRS) (P > 0.05), and post-operative IL6 either at baseline (10.03 +/- 4.09 vs. 10.73 +/- 3.54; p = 0.48) or at 24 hours after surgery (239.01 +/- 122.11 vs. 278.08 +/- 151.29; p = 0.30). Both groups had non-significant difference regarding post-operative nausea and vomiting.Conclusion: ESPB is as effective as PECS II-TTP with lower morphine consumption in the first 24 hours and comparable NRS, time to first analgesic request, and interleukin-6 levels. Both blocks were safe without any major complications.