Quality of Recovery After Breast Surgery: A Multicenter Randomized Clinical Trial Comparing Pectoral Nerves Interfascial Plane (Pectoral Nerves II) Block With Surgical Infiltration.

BACKGROUND: Pectoral nerves (PECS II) block is a popular regional analgesia technique for breast surgery. PECS II block or local infiltration by surgeon may improve outcomes including quality of recovery (QoR). METHODS: In this multicenter randomized clinical trial, 104 female patients undergoing breast surgery received: (1) PECS II block with local anesthetic and surgical infiltration with 0.9% saline (PECS group) or (2) PECS II block with 0.9% saline and surgical infiltration with local anesthetic (infiltration group). Patients, anesthetists, surgeons, nursing staff, and research assistants were blinded to group allocation. Patients received standardized general anesthesia and multimodal analgesia. The primary outcome was the global score (maximum score, 150; good recovery, 118) of the multidimensional (pain, comfort, independence, psychological, emotional) QoR-15 questionnaire measured 24 hours postoperatively. Secondary outcomes were pain, and its functional interference measured 24 hours and 3 months postoperatively using the Brief Pain Inventory (BPI) short form (0, optimal; 120, worst possible). Randomly assigned groups were compared on outcomes using the Wilcoxon rank-sum test, and the results were reported as median difference with 95% confidence interval. RESULTS: One hundred eight patients were recruited from August 17, 2016 to June 8, 2018, and 4 patients were withdrawn. Twelve patients from 104 had mastectomy, with the remainder having less invasive surgery. Baseline QoR-15 global scores reported as median [quartiles] were 135 [129, 143] in the PECS group and 139 [127, 143] in the infiltration group. The 24-hour QoR-15 global score reported as median [quartiles] was 131 [116, 140] in the PECS group and 123 [117, 143] in the infiltration group (P = .60), with median difference (95% confidence interval) of -2 (-9 to 5). The median difference reported as infiltration minus PECS for QoR-15 domains was pain 0 (-2 to 1), physical comfort -1 (-3 to 2), physical independence 0 (-2 to 1), psychological support 0 (0-0), and emotions 0 (-1 to 2) (P > .28). The BPI pain subscale at 24 hours (0-40, lower score indicates less pain), reported as median [quartiles], was 7 [2, 13] in the PECS group and 10 [5, 17] in the infiltration group (P = .15). The BPI global score at 24 hours, reported as median [quartiles], was 20 [7, 36] in the PECS group and 23 [10, 43] in the infiltration group (P = .34) and at 3 months was 0 [0, 14] and 0 [0, 11] (P = .85). CONCLUSIONS: After mostly minor surgery for breast cancer, PECS II block was not superior to local infiltration by the surgeon.

The development and anatomy of the gubernaculum in Hoxa11 knockout mice.

BACKGROUND: The gubernaculum is central to testicular descent, with recent evidence suggesting that it elongates to the scrotum like a limb bud. Homeobox (Hox) genes involved in limb bud outgrowth are expressed within the gubernaculum. Mice with homozygous Hoxa11 gene deletions have bilateral cryptorchidism. This study investigated the precise anatomical effects of Hoxa11 mutation on the mouse gubernaculum. METHODS: The pelvises of postnatal mice (n = 46; days 1-10) with Hoxa11 knockout (n = 19), heterozygotes (n = 11), and wild-type (n = 16) mice were serially sectioned and stained with hematoxylin and eosin. Immunohistochemistry was performed for the presence of desmin. RESULTS: Hoxa11 mutant mice had intraabdominal cryptorchid testes and highly convoluted vas deferentia. The gubernacular bulbs were abnormal, with no "outgrowth" and persistence of the prenatal "swelling reaction." Desmin immunostaining revealed the lack of undifferentiated mesenchymal cells usually seen as a "swirl" within the bulb and decreased formation of cremaster muscle. CONCLUSIONS: Hoxa11 may be involved in forming the growth center seen as the "swirl" of mesenchyme within the gubernacular bulb, consistent with these cells being required for gubernacular elongation during testicular descent. Hoxa11 mutations may well contribute to failure of gubernacular migration in boys with cryptorchidism.