Outpatient Breast Cancer Surgery Now Available

The fact that his patient wanted to go home 1 hours after surgery confirmed for Farzin Goravanchi, D.O., the success of an anesthetic technique that makes outpatient mastectomy and lumpectomy possible.

The patient who had just had a bilateral mastectomy removal of both breasts asked to go home because she felt so good, says Goravanchi, a doctor of ostoeopathic medicine and an anesthesiologist who specializes in providing pain control for M.D. Anderson patients undergoing breast cancer surgery.

"This was extensive surgery, but she had no side effects," he says.

Normally, a patient like this would have spent one or several days in the hospital, nauseous from the general anesthetic from the operation and from the opiate painkillers needed after she woke.

But the anesthetic procedure that Goravanchi used does not cause nausea or other problems. The revolutionary pain control technique is being used in a handful of hospitals nationwide and will become an increasingly available option in the more than 1,500 breast surgeries performed at M. D. Anderson each year.

Pain and painkillers produce nausea after surgery

Pain management during and after surgery, especially in the breast region, has long been tricky.

Scientists believe general anesthesia prevents unconscious patients from being aware of pain, but, for unknown reasons, anesthesia does not block pain signals that are transmitted to the brain during an operation.

When surgery patients wake up, they need strong painkillers to treat the pain their brain already was made aware of during surgery. Pain produces nausea and vomiting and so does use of opiates, the best of painkillers.

In addition, simply operating in the chest/breast area produces nausea in about half of patients. That means that the majority of women who undergo breast surgery, whether it is a minor lumpectomy or a major mastectomy, will experience side effects that often keep them in the hospital.

Procedure is learned to improve patient outcome

To address this problem, anesthesiologists at Duke University Medical Center pioneered a procedure known as a paravertebral block, that, like an epidural given during childbirth, provides "regional" pain control during breast surgery.

This technique blocks pain with injection of local anesthesia around the nerves in the region of the breasts. That means pain signals from the nerves never travel up the spinal cord and into the brain, says Goravanchi, who went to Duke to receive training in the procedure.

"There is no single painkiller that can adequately treat all pain without side effects," he says. "When paravertebral block is used in combination with other pain killers, this will reduce the amount of pain killers needed. The block will result in reducing or eliminating surgical pain and postoperative nausea which results from anesthesia. The effect of the block can last 12 hours after the surgery has ended. This will therefore reduce the amount of pain medications that you need. You will also be able to eat earlier since you have less nausea after surgery."

Goravanchi was trained in the use of the technique in early 2005, and by October, he had performed the procedure in 20 surgeries, all with great success. The volume of paravertebral blocks given is expected to grow significantly as more of the 11 breast surgeons at M. D. Anderson begin to offer the option, he says.

Goravanchi also predicts that the technique will soon become the predominant anesthesia used for all breast/chest surgeries at M. D. Anderson, including those for reconstructive plastic surgery. Another side benefit of the procedure is that it reduces numbness and tingling in the surgical scar, Goravanchi says.

"It's wonderful," he says. "The patients love it."

Regional technique now being used for other diseases

In addition to M. D. Anderson offering regional anesthesia for breast surgeries, it recently began introducing the concept in bone surgery, says Thomas Feeley, M.D., vice president, Medical Operations and head, Division of Anesthesiology and Critical Care.

For the past six months, anesthesiologist Krishna Boddu, M.D., has offered orthopedic patients a different technique of delivering regional anesthesia that Feeley says are "helping patients go home much earlier."

Feeley says the beauty of these techniques is that they offer "long-acting local anesthesia. This keeps affected areas numb much longer, which allows patients to recover quickly. The procedure also prevents patients from having to experience pain as well as taking narcotics, which are a mainstay after surgery."

Patients using regional anesthesia can be lightly sedated, so that while they are not completely unconscious, they are also not aware of the surgery as it takes place, he says.

"The procedures require a lot of skill on the part of an anesthesiologist to both technically perform it, and to win the confidence of patients that this is a good choice."

But Feeley believes that will happen, and that during the next decade regional anesthesia will result in many more M. D. Anderson outpatient surgeries. "And that is a good thing for patients," he says.