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Breast Surgery
Peri-operative Management of Tamoxifen
Tamoxifen increases venous thrombo-embolism (VTE) two to three-fold and may impair free-flap perfusion. Peri-operative handling therefore balances thrombosis risk against oncological benefit.
| Patient group | Additional VTE risk factors* | Tamoxifen | Thromboprophylaxis |
|---|---|---|---|
| < 60 y | ≥ 2 factors | Stop 21 days pre-op; restart when fully mobile (≥ 14 d post-op) | LMWH ± TEDS until mobile |
| 0–1 factor | Continue unless recent chemotherapy or expected surgical time > 90 min. If either present, stop 21 d pre-op | LMWH ± TEDS | |
| ≥ 60 y | ≥ 1 factor | Stop 21 d pre-op | LMWH ± TEDS |
| None | Continue | Standard VTE prophylaxis |
*Family history of VTE, BMI ≥ 30 kg m⁻², major cardiorespiratory or metabolic disease, recent (≤ 6 weeks) chemotherapy, planned prolonged immobility, microsurgical free-flap reconstruction.
Practical notes
- Minimum wash-out to halve plasma tamoxifen + metabolites ≈ 7 days, but 2–3 weeks achieves > 90 % elimination.
- Discuss cessation with the oncologist if metastatic disease, recent progression, or endocrine therapy is sole systemic treatment.
- Restart earlier (post-op day 1–2) after < 90-min day-case surgery provided the patient is mobile and on chemical prophylaxis.
- Free-flap breast reconstruction: most units suspend tamoxifen 4 weeks pre-op because of a higher flap-thrombosis rate.
Anaesthesia for Breast Surgery
Surgical Spectrum
- Mastectomy (simple, skin/nipple-sparing) ± sentinel node or axillary clearance.
- Wide local excision with sentinel node biopsy (day case).
- Onco-plastic/reconstructive: immediate or delayed implant, latissimus dorsi, TRAM or DIEP free flaps.
Pre-operative Priorities
- Optimise comorbidity and document cardiotoxic effects of anthracyclines/anti-HER2 agents.
- Explain regional techniques to reduce anxiety and postoperative pain.
- Where feasible, place IV access in the contralateral arm to minimise lymphoedema risk.
Intra-operative Management
| Domain | Key points |
|---|---|
| Airway | LMA for ≤ 90-min simple cases; ETT for axillary dissection, flap surgery or obesity. |
| Maintenance | Volatile or TIVA; avoid nitrous oxide during free-flap ischaemia. |
| Flap surgery | Maintain normothermia, normovolaemia, and systolic BP > 100 mm Hg after anastomosis. Goal-directed fluid therapy preferred to liberal crystalloid. |
| Analgesia | Use multimodal non-opioid baseline (paracetamol ± COX-2 inhibitor if GFR > 60 mL min⁻¹). |
| PONV | Dual prophylaxis (dexamethasone + 5-HT₃ antagonist). Add NK-1 antagonist if high risk. |
Regional anaesthesia–current Evidence
| Block | Dermatomes | Evidence summary 2023-25 |
|---|---|---|
| Thoracic paravertebral (TPV) | T2-T6 unilateral | Gold standard for major breast surgery; reduces acute pain, PONV and opioid use; meta-analysis shows comparable analgesia to interpectoral/pectoserratus (IP + PS) blocks with slightly higher technical risk. |
| PECS II / IP + PS | Pectoral nerves ± ICB, long thoracic | RCTs demonstrate similar 24-h opioid sparing to TPV and a 14 % absolute reduction in 12-week chronic pain after radical mastectomy. Rapid, easily learned, minimal haemodynamic impact. |
| Serratus anterior plane (SAP) | T2-T8 lateral | Meta-analysis shows analgesia equivalent to single-shot TPV for breast procedures; safer in coagulopathy. |
| Erector spinae plane (ESP) | T2-T8 | Comparable to TPV for pain scores but easier and lower complication rate; useful when TPV contraindicated. |
| Thoracic epidural | T1-T8 | Reserved for extensive free-flap surgery; higher failure and hypotension rates limit routine use. |
| Wound catheter / local infiltration | Incision only | Effective supplement to fascial-plane blocks for implant surgery. |
Technique selection should consider surgical extent, axillary involvement, coagulation status, and operator expertise. Catheter-based TPV or continuous PECS may benefit multi-day flap monitoring.
Cancer-recurrence and Anaesthesia
- Large-scale RCTs comparing propofol-paravertebral with sevoflurane-opioid techniques (n > 2100) found no difference in five-year disease-free survival.
- A 2024 trial-sequential meta-analysis of 15 RCTs (n ≈ 6000) confirmed no survival advantage for regional or propofol-based techniques.
- Current consensus: choose anaesthesia to optimise surgical conditions, analgesia, and rapid recovery. Potentially protective measures (adequate analgesia, avoidance of hypothermia or allogeneic transfusion, peri-operative NSAIDs and β-blockers where appropriate) may modulate inflammatory and adrenergic stress responses, but remain investigational.
Post-operative Care
- Day case: wide local excision ± SLNB; discharge with oral analgesia and fitness-for-discharge criteria.
- Ward / 23-h stay: modified radical mastectomy.
- HDU (24 h minimum): free-flap reconstruction (hourly flap checks, temperature, colour, Doppler signal).
- Encourage deep breathing exercises and early shoulder mobilisation to prevent stiffness and pulmonary complications.
Links
References:
- Sherwin, A. and Buggy, D. J. (2018). Anaesthesia for breast surgery. BJA Education, 18(11), 342-348. https://doi.org/10.1016/j.bjae.2018.08.002
- FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
- UK Clinical Pharmacy Association. Tamoxifen–Peri-operative issues. March 2024. periop-handbook.ukclinicalpharmacy.org
- See M et al. A validated risk-stratifying algorithm for peri-operative tamoxifen management reduces VTE. Int J Surg 2021. pmc.ncbi.nlm.nih.gov
- European Society of Anaesthesiology & Intensive Care. Paravertebral vs interpectoral/pectoserratus blocks for breast surgery: meta-analysis. Eur J Anaesthesiol 2025. pubmed.ncbi.nlm.nih.gov
- Chen Y et al. Ultrasound-guided PECS II block lowers chronic post-mastectomy pain: randomised trial. Pain Physician 2025. pmc.ncbi.nlm.nih.gov
- Singh R et al. Serratus anterior plane versus thoracic paravertebral block: systematic review and meta-analysis. Indian J Anaesth 2024. pmc.ncbi.nlm.nih.gov
- Panayi AC et al. Regional analgesia and cancer outcomes–current understanding 2024. Anaesth Pain Med 2024. pmc.ncbi.nlm.nih.gov
Summaries:
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© 2025 Francois Uys. All Rights Reserved.
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