AINAFTERBREASTCANCERSURGERY：乳腺癌手术后疼痛.ppt

TREATINGPAINAFTERSURGERY AndreaV Barrio MD FACSAttendingBreastSurgeonAssociateProgramDirector BreastFellowshipProgramTheBrynMawrHospital INTRODUCTION BreastcancermostcommoncanceramongwomenACSestimates232 340newcasesin2013 Secondmostcommoncausedeath39 620deathsin2013 www cancer org Painaftersurgery SCOPEOFTHEPROBLEM Estimated2 9millionbreastcancersurvivors2012Persistentpostsurgicalpaindemonstratedin25 50 ofpatientsundergoingbreastcancersurgery Painaftersurgery Introduction KehletH Lancet 2006 OVERVIEW AnatomyPresentationofbreastcancerCommonsurgicalproceduresforbreastcancerCausesofacutepost surgicalpainCausesofpost surgicalsensorydisturbancesLymphedemaTreatment Painaftersurgery BREASTANDAXILLARYANATOMY BREASTANATOMY FemalebreastLobules milk producingglands Ducts tubescarrymilkfromlobulestonipple Stroma fattytissueandconnectivetissuesurroundingductsandlobules Painaftersurgery THELYMPHATICSYSTEM Partofbody sdefensesystemMostlymphaticvesselsinthebreastconnecttolymphnodesunderthearm axillarynodes Someconnecttolymphnodesinsidethechest internalmammarynodes andsometothoseabovethecollarbone supraclavicularnodes Painaftersurgery Painaftersurgery Anatomy Painaftersurgery Anatomy HOWDOBREASTCANCERSPRESENT BREASTCANCERPRESENTATION ImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischarge Painaftersurgery BREASTCANCERPRESENTATION ImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischarge Painaftersurgery BREASTCANCERPRESENTATION ImagingabnormalityMassCalcificationsArchitecturaldistortionPalpablelumpSkinchangesChangesinnippleRashNippledischarge Painaftersurgery Diagnosisusuallymadewithimage guidedbiopsy IMAGE GUIDEDBREASTBIOPSY MinimallyinvasivebiopsystandardofcareforinitialdiagnosisofimagingabnormalitiesHematomaafterbiopsycanoftencausesignificantdiscomfort pain Painaftersurgery CANIDECREASEMYCHANCESOFHAVINGAPOST BIOPSYHEMATOMA OftenunavoidableAvoidbloodthinnersCoumadinAnti plateletsAspirin VitaminEFishoil Painaftersurgery SURGICALPROCEDURESOFTHEBREAST LUMPECTOMY IncisionismadeonthebreastRemovesthebreastcancerwitharimofnormaltissue Painaftersurgery RADIATIONTHERAPY TreatmentwithhighenergyraysthatdestroycancercellsThetreatmentisusedtokillcancercellsthatremaininthebreastTreatmentwithlumpectomyisalmostalwaysfollowedbyradiationtherapyRadiationtherapydecreasesthelikelihoodofthecancercomingbackinthebreastbymorethan50 Painaftersurgery MASTECTOMY Removaloftheentirebreastincludingthenippleandareola leavingthepectoralismajorintactWithamastectomy radiationisusuallynotnecessary Painaftersurgery SURGICALPROCEDURESOFTHEAXILLA AXILLARYLYMPHNODEDISSECTION Animportantpartofstagingbreastcancerisdeterminingifthelymphnodesunderthearmareinvolvedwithcancer10 40lymphnodesareremovedduringastandardALNDWasoncestandardofcareforbreastcancerpatients Painaftersurgery SENTINELLYMPHNODEBIOPSY SentinellymphnodeisthefirstlymphnodetoreceivedrainagefromthebreastoratumorinthebreastInjectionofradiotracer bluedyeintotheskinAgammaprobeusedtodetectradioactivityintheaxillaOnlynodesthatarehotand orblueareremoved Painaftersurgery CAUSESOFACUTEPOST SURGICALPAIN CELLULITIS ABSCESS Post operativeinfectionrare butcanoccurinbreastoraxillaIfsuperficial cantreatwithantibioticsIfdeeperinfectionsuspected mayrequireincisionanddrainageofinfectedfluid Painaftersurgery MONDOR SDISEASE ThrombosisofsuperficialveinPresentsasafirmtendercordoftissueusuallyfromupperabdomentolowerpartofbreastMayoccurafterbreastsurgerySelf limited resolveswithin2 8weeks Treatment HeatAnti inflammatorymedication Painaftersurgery SEROMA CollectionoffluidinsurgicalcavityNormalpartofwoundhealingSeromamaybecometenseandpainful particularlyinaxillaTreatment SimpleaspirationRepeatedasnecessary Painaftersurgery AXILLARYWEBSYNDROME CanbeseenafteranyaxillarysurgeryPresentsasaseriesoftender cord likestructuresthatarevisibleandpalpablebeneathaxillaryskinCordscanextenddownthearm intoforearm Painaftersurgery AXILLARYWEBSYNDROME Cording duetodisruptionoflymphaticvesselsduringaxillarysurgeryIncidence 20 aftersentinelnodebiopsy44 72 afteraxillarynodedissectionDevelopsinearlypost operativeperiodLimitsrangeofmotionTreatment PHYSICALTHERAPYtoimprovesymptomsandshortencourse Painaftersurgery SHOULDERABDUCTIONMORBIDITY Afteraxillarysurgery rangeofmotioninshouldermaybesignificantlylimitedMaybedueto PainScartissueAxillarywebsyndromeStudydemonstratedshoulderdeficits1weekaftersurgery 41 afterSLNbiopsy75 afterALNDSymptomsweresignificantlyimproved6monthsaftersurgery Painaftersurgery AshikagaT JSO 2010 CAUSESOFPOST SURGICALSENSORYDISTURBANCES BRACHIALPLEXOPATHY UsuallyrelatedtooperativepositioningInvolvesparesisofarmwithsensorychangesdistinctfromminorsensorydisturbancescausedbyinjurytointercostobrachialnervePrevention AppropriatepositioningincludingavoidinghyperextensionofthearmTreatment Physicaltherapy Painaftersurgery NUMBNESS AtincisionsiteafterlumpectomyorlymphnodebiopsyOfskinaftermastectomyInnerarmafterlymphnodebiopsyIntercostobrachialnerveoftensacrificedduringaxillarydissectionEvenifpreserved maybestretchedorinjured Painaftersurgery NUMBNESS Ifnerveissacrificed Numbnessunderarmremains butsymptomsbecomesignificantlylessdistressingIfnerveissimplystretched Normalsensationtotheinnerarmwillreturn butmaytakeseveralmonths Painaftersurgery PHANTOMBREASTPAIN MostcommonaftermastectomyJohnsHopkinsstudyreported39 womenhadphantomsensationsaftermastectomyIncidencewassimilarwithorwithoutreconstructionDuringmastectomy smallnervesbetweenbreastandskinarecutPhantomsensationsmayberelatedtoalteredconnectionbetweenthecutnerveandthebrain Painaftersurgery PHANTOMBREASTPAIN Commonsensationsreported PainanddiscomfortItchingPinsandneedlesTinglingPressureBurningThrobbingTreatment Exerciseor breast massagemayhelpPainmedicationforseverecases Painaftersurgery 18SENSATIONSAFTERBREASTCANCERSURGERY 187patientswithbreastcancercompletedquestionnaireat3 6 12 24and60monthsaftersurgery141lumpectomy46mastectomyAllhadaxillarysurgery133sentinelnodebiopsy54axillarylymphnodedissection Painaftersurgery BaronR ASO 2006 18SENSATIONSAFTERBREASTCANCERSURGERY TenderSorePullAcePainfulTwingeTightStiffPrick ThrobShootTingleNumbBurnHardSharpNagPenetrate Painaftersurgery BaronR ASO 2006 18SENSATIONSAFTERBREASTCANCERSURGERY Mostprevalentsensationsatbaseline tendernessSensationslessprevalentandlesssevereaftersentinelnodebiopsycomparedtoaxillarydissectionSomesensationswereprevalent evenat5yearsTendernessandtwingesafterSLNbiopsyTightnessandnumbnessafterALND Painaftersurgery BaronR ASO 2006 18SENSATIONSAFTERBREASTCANCERSURGERY StudyprovidesvaluableimportantinformationregardingwhatistobenormalandexpectedpartofhealingprocessMostsensationsobserved evenifprevalent werenotsevereordistressing Painaftersurgery BaronR ASO 2006 LYMPHEDEMA Potentialcauseofpost surgicalpainLimbswellingoccursasaresultofproteinrichfluidaccumulatinginthesofttissuesAdditionalfluidbuild upinarmcancausetingling achingandheavinessIncidence3 16 ofwomenundergoingaxillarysurgery Painaftersurgery RISKFACTORSFORLYMPHEDEMA Manyretrospectivestudiesevaluatingassociationbetweenriskfactorsandlymphedema1AxillarylymphnodedissectionMastectomyObesityRadiationInfectionIpsilateralupperextremityinjuryRecentstudyreportedthatsaunausewasonlylifestyleriskfactorassociatedwithlymphedema 1McLaughlinSA Oncology 2012 ShowalterS ASO 2013 Painaftersurgery TREATMENT TIPSTOREDUCESYMPTOMS POST OPERATIVEEXERCISE Earlypost operativeexercisemostimportantInareviewof10studies introductionofupperextremityexerciseasearlyaspost operativeday1afteraxillarysurgeryshowedclearbenefitoverdelayed day5 7 forshoulderrangeofmotion Structuredexerciseprogramswithaphysicaltherapistsignificantlyimprovepost operativerangeofmotionandshoulderdysfunction Painaftersurgery McNeelyM Cochranereview 2010 PHYSICALTHERAPY Painaftersurgery PHYSI