Effect of ultrasound-guided stellate ganglion block combined with erector spinal plane block on postoperative recovery quality of breast cancer patients: a randomized controlled trial

Effect of ultrasound-guided stellate ganglion block combined with erector spinal plane block on postoperative recovery quality of breast cancer patients: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of ultrasound-guided stellate ganglion block combined with erector spinal plane block on postoperative recovery quality of breast cancer patients: a randomized controlled trial Xuebing Wang, Zhenqi liu, Yong Pang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6178697/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background There are many reports demonstrating that regional anaesthesia improves the quality of postoperative recovery in patients undergoing breast cancer surgery; however, the enhancement of the quality of postoperative recovery by a combined block of regional anaesthesia has rarely been investigated. We compared whether stellate ganglion block (SGB) combined with erector spinal plane block (ESPB) was more effective than ESPB alone in improving the quality of postoperative recovery in female patients undergoing unilateral modified radical mastectomy (MRM) . Methods Ninety female patients were selected for elective proposed unilateral modified radical mastectomy and randomly divided into combined block group (SE group) and control group (E group), with 45 cases in each group. The same anesthetic drugs were used for induction and maintenance in both groups, and ultrasound-guided right stellate ganglion block combined with a plane block of the affected erector spinae muscle was performed 15 min before induction of anesthesia in the SE group, while only a plane block of the affected erector spinae muscle was performed in the E group. QoR-15 scores on the first postoperative day and postoperative visual analog scores (VAS) at different time points were observed in both groups; intraoperative opioid use was observed in both groups. Results QoR-15 scores on the first postoperative day were significantly improved in the SE group (122.91 ± 6.15) compared with the E group (114.80 ± 7.01) (P < 0.05); the SE group showed lower VAS scores than the E group at 12h and 24h postoperatively in the resting (1.53 ± 0.50, 1.02 ± 0.69; 1.80 ± 0.54, 1.51 ± 0.62, respectively) and active (respectively 2.42±0.49, 1.80±0.58; 3.16±0.52, 2.31±0.46) states(P<0.05); intraoperative remifentanil use was lower in the SE group (487.11±26.59ug, 570.67±31.29ug, respectively, P<0.05). Conclusion After unilateral MRM, the combined block group was more effective than ESPB alone in reducing opioid consumption and lowering postoperative VAS scores, improving the quality of patients' postoperative recovery. stellate ganglion block erector spinae plane block stellate ganglion block combined with erector spinae plane block quality of postoperative recovery breast cancer Figures Figure 1 Introduction Breast cancer, as the second most common cancer after lung cancer and also the most prevalent malignant tumor among women worldwide, has shown an increasing trend in its incidence in recent years, and the disease is one of the leading causes of cancer deaths among women worldwide[ 1 ]. Although there are many treatment options for breast cancer, the main treatment choice for breast cancer remains surgery, with modified radical mastectomy (MRM) being the most common surgical treatment option today[ 2 ]. Because MRM is more invasive, most patients undergoing surgery experience acute postoperative pain, and if acute postoperative pain is not adequately controlled, it may even further evolve into chronic pain, resulting in post-mastectomy pain syndrome (PMPS), which can range from 20–68%[ 3 ]. This not only increases the difficulty of treatment, but also has a serious impact on the patient's postoperative recovery, increasing the incidence of postoperative complications, delaying wound healing, and prolonging the patient's hospitalization. Therefore, effective postoperative analgesic strategies are essential to promote patients' postoperative recovery [ 4 ] ESPB has been gradually used in breast cancer surgery because it is simple, safe, easy to perform, and can provide good postoperative analgesia to patients, and its analgesic effect is equivalent to thoracic paravertebral nerve block (TPVB), which is considered to be an effective alternative to TPVB in breast cancer surgery[ 5 , 6 ]. The stellate ganglion block, which covers a wide range of indications, plays an important role in the treatment, diagnosis, and prognostic evaluation of a variety of diseases, and has also been gradually used in breast cancer surgery [ 7 ]. Although studies by Yang[ 8 ]and Wiech[ 9 ]have shown that both SGB and ESPB can improve the quality of postoperative recovery in breast cancer patients, respectively, there is a lack of evidence that the combination of the two is more effective in improving the quality of postoperative recovery in patients. The purpose of this study was to compare whether the combination of ultrasound-guided SGB and EPSB is more effective than EPSB alone in improving the quality of postoperative recovery in women undergoing unilateral MRM. Materials and method 1.1 Study subjects This experiment has been approved by the Ethics Committee of the Affiliated Hospital of Chuanbei Medical College (Approval No. 2024ER329-1), and the patients and their families signed the informed consent form before the experiment.90 surgical patients who underwent unilateral modified radical mastectomy from June 2024 to October 2024 at the Affiliated Hospital of Chuanbei Medical College were selected, and divided into the combined block group (45 cases) and the control group (45 cases). Inclusion Criteria: Breast cancer patients scheduled for elective unilateral MRM were screened and recruited during preoperative evaluation, and preoperative education was routinely provided to recruited patients. The inclusion criteria were as follows: a. Patients with a clear preoperative diagnosis who underwent unilateral MRM; b. Age 18-65 years; c. Class I or II according to the American Society of Anesthesiologists Physical Condition Assessment System. Exclusion Criteria: a. Preoperative combination of serious heart, liver, kidney and other dysfunctional diseases; b. Allergy to the local anesthetics used in the study, infection at the puncture site, abnormal coagulation function; c. Cognitive function, hearing and speech disorders, history of mental illness, difficulty in communicating, or difficulty in cooperating with the patients with mental disorders. Withdrawal Criteria:(i) Failure of SGB and/or ESPB; (ii) Patients with adverse reactions to the drugs used or other reasons that require stopping the study midway. 1.2 Randomization A series of random sequences were generated by an online randomizer and sealed in opaque envelopes by staff not involved in this study. All participants were randomized in a 1 : 1 ratio into a combined block group (SE group) and a control group (E group). All patients, anesthesiologists, and outcome assessors were unaware of the study group assignment. 1.3 Anesthesia interventions The SE group received a stellate ganglion block combined with a planar block of the erector spinae muscle 15 minutes before induction of anesthesia, and an attending anesthesiologist familiar with ultrasound-guided nerve blocks used an ultrasound machine to locate the longissimus cervicis muscle at the level of the C6 cervical vertebrae. After local anesthesia was administered to the correct puncture site, an in-plane needle approach was performed to penetrate the muscle surface. After confirming that there was no cerebrospinal fluid, blood, or gas on aspiration, SGB was performed by injecting 6 ml of 0.25% ropivacaine hydrochloride. The presence of Horner's syndrome on the side of the block confirmed the success of SGB. Then the patient was placed in the lateral position, with the affected side facing upward, and the transverse plane block technique was used, with the probe placed in the T5 transverse process and the probe moved 2 cm to the affected side, and the ultrasound image showed the trapezius, rhomboid, erector spinae, and T5 transverse process in sequence, and the in-plane approach was performed up to the T5th transverse process, and 20 ml of 0.375% loperamide hydrochloride was injected after being returned to the bloodless side prior to each injection. After successful implementation of the block, the patient's vital signs were closely monitored to prevent any complications. In the control group (Group E), a planar block of the erector spinae muscle was performed only before the induction of anesthesia. 1.4 Anesthesia procedures Both groups of patients were operated with intravenous inhalation combined general anesthesia, and anesthesia induction and tracheal intubation were performed by the same anesthesiologist. Upon entering the operating room, patients underwent routine examinations, including monitoring of heart rate (HR), mean arterial pressure (MAP), pulse oximetry (SpO2) and electrocardiogram (ECG). Peripheral intravenous fluid access was established. For induction of anesthesia, midazolam 0.05 mg/kg, sufentanil 0.3μg/kg, propofol 1.5-2.0 mg/kg, and atracurium benzenesulfonate 0.15 mg/kg were given in sequence, and while slowly injecting the drugs, the patient's blood pressure, heart rate, electrocardiogram, and changes in BIS were closely observed, and attention was paid to the patient's consciousness and respiration, so that assisted ventilation was given in a timely manner, and after the inotropic drugs had taken full effect, the patient's blood pressure, heart rate, electrocardiogram and changes in BIS were monitored using visualization. After the inotropic medication was fully effective, tracheal intubation was carried out using a visual laryngoscope. After intubation, mechanical ventilation was started, and the parameters of the ventilator were adjusted to a tidal volume of 6-8 ml/kg, a respiratory rate of 12-16 breaths/min, an end-expiratory partial pressure of carbon dioxide of 35-45 mmHg, and a respiratory ratio of 1:1. During the operation, the depth of anesthesia was maintained by inhalation of 2.0% sevoflurane and pump injection of remifentanil hydrochloride, and 2mg of atracurium benzenesulfonate was given intermittently according to the needs of the operation. The pumping rate of remifentanil was appropriately adjusted according to the changes in BIS value, blood pressure and heart rate to ensure that the patient was in an appropriate state of anesthesia. The principle of fluid replenishment was 6-8ml/kg/h, mainly crystalloid. During the operation, adequate oxygenation and hemodynamic stability were maintained. Systolic blood pressure lower than 20% of the preoperative basal value or lower than 90mmHg was regarded as hypotension, and 6mg of ephedrine was injected intravenously, while systolic blood pressure higher than 20% of the basal value or higher than 180mmHg was lowered by injecting 15mg of urocortisol intravenously, and the heart rate of the patient was maintained at between 50-100 beats/min with the use of atropine or esmolol. 1.5 Awakening from anesthesia and postoperative analgesia Administration of atracurium benzenesulfonate injection was discontinued 40 minutes before the end of the procedure, and a final dose of 10μg sufentanil was administered and remifentanil was discontinued 30 minutes before the end of the procedure. Sevoflurane was discontinued 15 minutes before the end of the procedure and the patient was given 10-15 minutes of pure oxygen inhalation to help clean the lungs. Suction care was performed and criteria for extubation were confirmed before removal of the endotracheal tube. Patients were admitted to the post anesthesia care unit (PACU) for routine monitoring and transferred to the ward after meeting criteria for discharge from the PACU. Patients in both groups received postoperative intravenous self-controlled analgesia (PCIA). The analgesic regimen consisted of 150 ug of sufentanil, 8 mg of Butorphanol, and 5 mg of Tolansetron diluted in saline to 150 mL.The PCIA parameters were determined as follows:a background infusion rate of 1.5 mL/h, a single dose of 0.5 mL, and a lockout time of 15 minutes for a total duration of 24 hours. If the postoperative VAS score on return to the room was >7, the attending nurse could administer a rescue dose of oxycodone (5 mg). 1.6 Outcome measurement The primary outcome was the assessment of the patients using the Chinese version of the Global Quality of Recovery Rating Scale QoR-15.The QoR-15 scale assesses the patients' postoperative physical recovery from five aspects totaling 15 questions, namely pain, physical comfort, physical independence, psychological support, and emotional state.The score of the QoR-15 ranges from 0 to 150, with higher scores suggesting better quality of postoperative recovery[10]. Secondary regressions included recording the dose of opioids used during general anesthesia, general information; a team member who did not know the subgroups recorded postoperative patients' VAS scores at 2h, 6h, 12h, and 24h, the incidence of postoperative adverse reactions (e.g., nausea, vomiting, itching, etc.), the time to the first self-administered analgesia, number of effective presses on the analgesic pump at 24h, number of cases of additional remedies for analgesia, the time to the first time of getting out of bed, the time to the first postoperative total hospitalization time surgery and the incidence of chronic pain in the second three months. 1.7 Sample size calculation In our preliminary study, the mean standard deviation (SD) of the QoR-15 scores in the postoperative combined block group and the control group were 121.2 ± 6.3 and 111.2 ± 6.5, respectively, and setting the type I error rate of α = 0.05 and the test efficacy of β = 0.9, a minimum of 34 samples in each group was calculated using the GPower3.1 software, taking into account the 20% loss to followup rate, and a minimum of 34 samples in each group were required. 45 patients were finally recruited. 1.8 Statistical analysis Data were analyzed using SPSS 27.0 statistical software. Continuous data were expressed as mean standard deviation and t-tests were used for comparisons between groups. Within-group comparisons at different time points were performed using repeated measures ANOVA. Categorical data were expressed as proportions (%), and comparisons between groups were performed using the chi-square test and exact probability method. p< 0.05 was statistically significant. Results Comparison of general information A total of 90 cases were collected from June 2024 to October 2024, of which none withdrew from the study (study flow chart shown in Fig.1). Patient demographic characteristics, including weight, height, age, admission mean arterial pressure (MAP), heart rate (HR), and ASA classification, did not differ significantly between the two groups. Differences in anesthesia induction time, anesthesia maintenance time, anesthesia recovery time, and operation time were not statistically significant (P> 0.05) between the two groups, as shown in Table 1. Table 1 Demographic profile of two groups Project SE group (N=45) E group (N=45) P Age (years) 49±7.79 48.47±7.53 0.742 ASA grade I/II, n (%) 33（73%/12(27%) 31(69%)/14(31%) 0.642 Height (cm) 156.07±5.35 156.04±6.50 0.986 Weight (kg) 59.40±7.25 57.98±7.83 0.374 MAP（mmHg） 93.14±11.42 94.28±10.89 0.631 HR（times/min） 77.20±8.34 74.67±7.51 0.134 Anesthesia induction time （min） 5.89±1.19 5.82±1.19 0.791 Anesthesia maintenance time （min） 139.00±8.88 140.81±11.83 0.595 Anesthesia recovery time （min） 18.69±2.06 19.11±2.44 0.378 Surgical time （min） 124.98±9.64 126.78±12.04 0.436 Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. ASA: American society of Anesthesiologist physical status. Comparison of the quality of postoperative recovery Compared with the control group, the QoR-15 score was significantly higher in the SE group on the first postoperative day (P < 0.05), and the difference in the QoR-15 score on the first postoperative day had exceeded the reported Minimal clinically important difference (MCID), which means that an increase in the QoR-15 of 6.0 points if it is equal to or more than 6.0 points implies clinically important improvement[11]. As shown in Table 2. Table2 Comparison of QoR-15 scores among two groups Project SE group (N=45) E group (N=45) P Preoperative QoR-15 scores 136.56±2.11 136.60±2.20 0.961 QoR-15 scores on POD1 121.82±6.12 113.40±6.16 ＜0.001* Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. POD1, postoperative day 1, QoR-15, quality of recovery-15. Comparison of intraoperative opioid use When comparing and analyzing the amount of intraoperative sufentanil used in the two groups, no significant difference was observed (P > 0.05). In contrast, compared with the control group, the demand for intraoperative remifentanil in the SE group was significantly lower, which was statistically significant (P < 0.05). As shown in Table 3. Table 3 Comparison of Sufentanil dose and Remifentanil dose among two groups. Project SE group (N=45) E group (N=45) P Sufentanil dose/ug 27.87±2.12 27.36±2.31 0.279 Remifentanil dose/ug 487.11±26.59 570.67±31.29 ＜0.001* Data is represented as mean±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05.The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. Comparison of the use of postoperative analgesic pump Compared with the control group, the SE group had a prolonged time to the first postoperative analgesic pump press and a lower total number of 24-h analgesic pump presses (P < 0.05), indicating that the SE group had better analgesia than the E group in the postoperative period. No postoperative rescue analgesia was performed in both groups. As shown in Table 4. Table 4 Comparison of the first postoperative analgesic pump press and number of 24h analgesic pump presses among two groups Project SE group (N=45) E group (N=45) P First ACP time/h 11.67±2.15 9.04±2.13 ＜0.001* 24h APC/times 7.64±3.27 9.98±2.78 ＜0.001* Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. APC: analgesic pump compressions Comparison of postoperative VAS scores at rest and during activity Compared with the control group, the SE group had lower VAS scores in the resting and active states at 12h and 24h postoperatively, and the difference was statistically significant (P 0.05). As shown in Tables 5 and 6. Table 5 Comparison of postoperative VAS scores at rest between the two groups Project SE group (N=45) E group (N=45) P Postoperative 2h VAS 0.78±0.42 0.91±0.35 0.109 Postoperative 6h VAS 1.13±0.54 1.31±0.59 0.144 Postoperative 12h VAS 1.53±0.50 1.80±0.54 0.018∗ Postoperative 24h VAS 1.02±0.69 1.51±0.62 ＜0.001∗ Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. Table 6 Comparison of VAS scores at postoperative activities between the two groups Project SE group (N=45) E group (N=45) P Postoperative 2h VAS 1.24±0.43 1.36±0.48 0.225 Postoperative 6h VAS 1.82±0.49 2.04±0.63 0.067 Postoperative 12hVAS 2.42±0.49 3.16±0.52 ＜0.001∗ Postoperative 24h VAS 1.80±0.58 2.31±0.46 ＜0.001∗ Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05，The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. Comparison of other postoperative data between the two groups Compared with the control group, the SE group demonstrated an early time of first out-of-bed activity and a short total postoperative hospitalization time after surgery, with statistically significant differences (P < 0.05), and there was no significant difference between the two groups in the incidence of postoperative adverse reactions (including nausea and vomiting, skin itching, vertigo, and so on), and the incidence of chronic pain in the three-month postoperative period (P > 0.05). As shown in Table 7. Table 7 comparison of other postoperative data between the two groups Project SE group (N=45) E group (N=45) P Time to FPD/h 21.56±1.75 23.09±1.91 ＜0.001∗ Total postoperative hospitalization/d 5.62±0.91 6.42±0.86 ＜0.001∗ Incidence of PAR/n (%) 3(6.6%) 8(17.7%) 0.108 Incidence of PCP at 3 months /n (%) 17(37.7% 21(46.6%) 0.393 Data is represented as mean ±SD. The symbol ∗ represents the comparison between the SE group and the E group, with P < 0.05，The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. FPD: first postoperative bedtime; PAR: postoperative adverse reactions; PCP: Postoperative chronic pain. Discussion The main hypothesis of our study, that breast cancer patients undergoing unilateral MRM using SGB + ESPB achieve better quality of postoperative recovery, was confirmed according to the results of the study. Compared with the control group, the overall postoperative QoR-15 score in the SE group was 8 points higher than that in the control group (Table 1 ), which exceeded the MCID reported by Myles, suggesting that the enhancement of the quality of postoperative recovery by SGB in combination with ESPB was superior to that of ESPB alone. However, the QoR-15 scores of the control group differed from those previously derived by Yao[ 12 ], which may be related to biological, psychological, and social factors of geographic and inter-individual variability[ 13 ]. MRM, due to its surgical scope involving extensive chest wall tissues and complex nerve injuries, can often result in patients experiencing different degrees of acute or chronic pain after surgery, which is detrimental to the postoperative recovery process and postoperative quality of life[ 14 , 15 ]. In recent years, with the development and promotion of the concept of accelerated recovery after surgery (ERAS), regional anesthesia block techniques have been gradually applied to various types of breast cancer surgery[ 4 , 16 ]. Studies have shown[ 17 ] that regional anesthesia block can reduce patients' postoperative pain as well as help to reduce surgical stress, which has a positive impact on patients' postoperative recovery. According to a meta-analysis[ 18 ], regional anesthetic blocks commonly used in breast cancer surgery include paravertebral nerve block, thoracic nerve-2 block, anterior serratus plane block, erector spinae plane block, rhomboid intercostal block, and local anesthesia. However, compared with the erector spinae plane block, other anesthesia techniques show some limitations in their application. For example, paravertebral nerve block can lead to complications such as hypotension, bradycardia, and local anesthetic toxicity; after thoracic nerve block, the diffusion of local anesthetic in the surgical area can lead to an increase in electrical resistance, which interferes with surgical procedures; and local anesthesia is not as effective as regional anesthesia in terms of analgesic effect [ 19 – 21 ]. ESPB was firstly proposed as a novel anesthesia technique by Forero et al. for the first time in 2016, ESPB not only blocks the ventral and dorsal branches of spinal nerve roots, but also blocks the fiber traffic branches containing connections between the sympathetic ganglion and spinal nerves, which produces analgesic effects on the trunk and viscera. Numerous studies[ 6 , 9 , 12 , 22 , 23 ] have shown that ESPB is effective in providing analgesia after breast cancer surgery, reducing the amount of opioids used in patients undergoing breast cancer surgery as well as improving the quality of postoperative recovery. However, Forero et al. also suggested that ESPB of the T5 transverse process on one side only blocked the innervation area of the ipsilateral T3-T9 spinal nerves [ 5 , 24 ], whereas the innervation area of the breast was the lateral and anterior cutaneous branches of the T2-T6 spinal nerve branches as well as several branches of the supraclavicular nerves, and the analgesic effect of the ESPB was smaller than that of thoracic nerve block[ 6 , 25 ], which suggested that ESPB could not provide adequate regional analgesia in breast cancer surgery. adequate regional analgesia. SGB has not only demonstrated significant efficacy in the treatment of painful disorders, but also for non-painful disorders[ 26 ]. SGB can regulate and attenuate neuropathic pain by promoting vasodilation at the surgical site, accelerating the clearance of inflammatory mediators, and inhibiting the transfer of leukocytes to the site of inflammation, reducing the production of inflammatory mediators[ 27 ]. Some studies have shown[ 8 , 28 – 31 ] that preoperative SGB can enhance sleep quality, treat hot flushes, improve symptoms of lymphedema, reduce the incidence of postoperative pain and PMPS in patients undergoing breast cancer surgery, and recover gastrointestinal function better in the postoperative period, improving the quality of postoperative recovery in patients. In conclusion, we believe that SGB combined with ESPB can produce better postoperative analgesia and higher quality of postoperative recovery for patients. In recent years, with the continuous development of ultrasound technology, ultrasound-guided regional anesthesia block technology has become increasingly mature and widely used in clinical practice, and the safety and precision of ultrasound-guided SGB and ESPB have been greatly improved compared with the traditional technology, and all of the experiments were performed under ultrasound guidance. The right SGB was chosen for this experiment because it showed more significant antioxidant effects and was able to reduce the concentration of catecholamines in the blood, which in turn reduced the stress response[ 32 ]. In our study, postoperative VAS scores, intraoperative opioid requirements, and postoperative analgesic pump requirements were lower in the SE group compared to the control group, demonstrating longer duration of analgesia. This result is also supported by the findings of Geng [ 33 ] et al. who reported that SGB combined with thoracic nerve block was more effective in relieving stress and reducing acute postoperative pain than single thoracic nerve block, and that the analgesic effect of SGB could be sustained for up to 12 h. This is in line with the conclusion that SGB provides effective analgesia, as reported in several previous clinical trials. Early activity is an important component of ERAS and plays an important role in reducing the risk of postoperative complications, shortening the length of hospitalization, and reducing the financial burden on patients[ 34 ]. Temple-Oberle[ 35 ]et al. concluded that early activity within 24h postoperatively plays a positive role in the postoperative recovery of patients undergoing breast surgery. One of the main reasons for impaired early postoperative activity is that surgery leads to inflammation and other disruptions of homeostasis in the body [ 21 ]. Our study showed that compared with the control group, the SE group had an earlier time to first get out of bed and a shorter total postoperative hospital stay, which indicated that SGB combined with ESPB could more effectively eliminate the adverse effects of surgery, accelerate the recovery process of patients' early postoperative activities, and promote the overall recovery of the patients; however, the two groups of patients did not show a significant difference in the incidence of postoperative adverse reactions. No conclusive evidence was found in our study to support the hypothesis that SGB reduces PMPS in patients undergoing breast cancer surgery. The two groups of patients did not demonstrate a significant difference in the incidence of postoperative chronic pain, a result that diverges from the findings of previous studies, probably because the results of our study were the incidence of PMPS at three months postoperatively, which is a relatively short period of time of observation, and does not effectively reflect the long-term effect of SGB on the incidence of PMPS. This study has some limitations. First, we selected only female patients who underwent MRM, with a single type of surgery and gender, and a relatively small sample size. Second, we only recorded the incidence of chronic pain at three months postoperatively and did not compare the severity of chronic pain occurrence. In addition, certain factors, such as the quality of postoperative sleep, recovery of postoperative gastrointestinal function, and assessment of postoperative lymphedema symptoms were not recorded or compared in this study. In future studies, for a more scientifically designed and more comprehensive assessment of the effectiveness of ultrasound-guided SGB combined with ESPB in breast cancer surgery, we recommend more multicenter studies that include a more diverse group of participants, including male patients and patients undergoing surgery for different types of breast cancer, as well as a comprehensive documentation of the insufficient parts of the current study for a more comprehensive and in-depth comparative analysis Conclusion In breast cancer patients undergoing MRM, the combined block group was more effective than ESPB alone in reducing opioid use and lowering postoperative VAS scores, improving the quality of patients' postoperative recovery. The combined block approach also helped promote early activity and shorter hospital stays. Abbreviations SGBStellate ganglion block ESPB Erector spinae plane block MRM Modified radical mastectomy QoR-15 Quality of recover-15 VAS Visual analogue scale PMPS Post-mastectomy pain syndrome, ASA American society of anesthesiologists TPVB Thoracic paravertebral nerve block HR Heart rate MAP Mean arterial pressure BIS Bispectral index SpO2 Pulse oxygen saturation ECG Electrocardiogram PACU Post-anesthetic care unit PCIA Patient controlled intravenous analgesia MCID Minimal clinically important difference POD1 postoperative day 1 APC analgesic pump compressions FPD first postoperative bedtime PAR postoperative adverse reactions PCP Postoperative chronic pain ERAS enhanced recovery after surgery Declarations Acknowledgements Not applicable. Ethical approval and consent to participate This study received approval by Medical Ethics Committee of Affiliated Hospital of North Sichuan Medical College (2024ER329-1) on 22/05/2024, with registration on Clinicaltrials. Chinese Clinical Trial Registry (ChiCTR2400085892) on 20/06/2024. Written informed consent was obtained from every patient by the investigators, and that this work was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable Data Availability The datasets generated and/or analyzed during this study are not publicly available due to institutional policy on data confidentiality but are available from the corresponding author on reasonable request. Competing Interest The authors declare that they have no competing interests Funding This study did not receive any funding. Author Contribution XW: Conceptualization, methodology, investigation, formal analysis, writing – original draft, review, and editing. ZL: Conceptualization, methodology, formal analysis, writing – review and editing. YP: Conceptualization, methodology, investigation, formal analysis, writing – review and editing, supervision. All authors read and approved the final manuscript. Authors' information Affiliated Hospital of North Sichuan Medical College, Nanchong,Dept of Anesthesiology, Affiliated Hospital of North Sichuan Medical College References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA Cancer J Clin 2024, 74 (3):229-263. Huang S, Yang Q, Zheng X, Chow KM, Wu J, Zhu J: Predictors of surgery choices in women with early-stage breast cancer in China: a retrospective study . BMC Cancer 2023, 23 (1):23. Chappell AG, Yuksel S, Sasson DC, Wescott AB, Connor LM, Ellis MF: Post-Mastectomy Pain Syndrome: An Up-to-Date Review of Treatment Outcomes . JPRAS Open 2021, 30 :97-109. 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Yang X, Wu Q, Wang H, Zhang Y, Peng X, Chen L: Effects of Ultrasound-Guided Stellate Ganglion Block on Postoperative Quality of Recovery in Patients Undergoing Breast Cancer Surgery: A Randomized Controlled Clinical Trial . J Healthc Eng 2022, 2022 :7628183. Wiech M, Piwowarczyk P, Mieszkowski M, Tuyakov B, Pituch-Sala K, Czarnik T, Kurylcio A, Czuczwar M, Borys M: The quality of recovery after erector spinae plane block in patients undergoing breast surgery: a randomized controlled trial . BMC Anesthesiol 2022, 22 (1):222. Stark PA, Myles PS, Burke JA: Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15 . Anesthesiology 2013, 118 (6):1332-1340. Myles PS, Shulman MA, Reilly J, Kasza J, Romero L: Measurement of quality of recovery after surgery using the 15-item quality of recovery scale: a systematic review and meta-analysis . Br J Anaesth 2022, 128 (6):1029-1039. Yao Y, Li H, He Q, Chen T, Wang Y, Zheng X: Efficacy of ultrasound-guided erector spinae plane block on postoperative quality of recovery and analgesia after modified radical mastectomy: randomized controlled trial . Reg Anesth Pain Med 2019. Schreiber KL, Belfer I, Miaskowski C, Schumacher M, Stacey BR, Van De Ven T: AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery . J Pain 2020, 21 (3-4):294-305. Gärtner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H: Prevalence of and factors associated with persistent pain following breast cancer surgery . Jama 2009, 302 (18):1985-1992. Shockney LD: Pain following breast cancer surgery: a quality-of-life issue . Arch Surg 2010, 145 (3):224-225. Lombana NF, Mehta IM, Zheng C, Falola RA, Altman AM, Saint-Cyr MH: Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions . Proc (Bayl Univ Med Cent) 2023, 36 (4):501-509. Sekandarzad MW, van Zundert AAJ, Lirk PB, Doornebal CW, Hollmann MW: Perioperative Anesthesia Care and Tumor Progression . Anesth Analg 2017, 124 (5):1697-1708. An R, Wang D, Liang XL, Chen Q, Pang QY, Liu HL: The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: A network meta-analysis . Front Oncol 2023, 13 :1083000. Bakshi SG, Karan N, Parmar V: Pectoralis block for breast surgery: A surgical concern? Indian J Anaesth 2017, 61 (10):851-852. Naja Z, Lönnqvist PA: Somatic paravertebral nerve blockade. Incidence of failed block and complications . Anaesthesia 2001, 56 (12):1184-1188. Wong HY, Pilling RJ, Young BWM, Owolabi AA, Onwochei DN, Desai N: Corrigendum to: 'Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis' [Journal of Clinical Anesthesia Volume 72 (2021)/Article 110274] . J Clin Anesth 2021, 75 :110491. Guan HY, Yuan Y, Gao K, Luo HX: Efficacy and safety of erector spinae plane block for postoperative analgesia in breast cancer surgery-A systematic review and meta-analysis . J Surg Oncol 2023, 127 (6):905-920. Ben Amor M, Ben Marzouk S, Souihli S, Fouzai B, Ben Amor F, Magherbi H: Postoperative Analgesia in Breast Cancer Surgery: Efficiency and Safety of Ultrasound Guided Erector Spinae Plane Block, a randomized controlled double blinded trial . Tunis Med 2023, 101 (6):559-563. Forero M, Rajarathinam M, Adhikary S, Chin KJ: Continuous Erector Spinae Plane Block for Rescue Analgesia in Thoracotomy After Epidural Failure: A Case Report . A A Case Rep 2017, 8 (10):254-256. Riccio CA, Zeiderman MR, Chowdhry S, Brooks RM, Kelishadi SS, Tutela JP, Choo J, Yonick DV, Wilhelmi BJ: Plastic Surgery of the Breast: Keeping the Nipple Sensitive . Eplasty 2015, 15 :e28. Singh H, Rajarathinam M: Stellate ganglion block beyond chronic pain: A literature review on its application in painful and non-painful conditions . J Anaesthesiol Clin Pharmacol 2024, 40 (2):185-191. Kumar N, Thapa D, Gombar S, Ahuja V, Gupta R: Analgesic efficacy of pre-operative stellate ganglion block on postoperative pain relief: a randomised controlled trial . Anaesthesia 2014, 69 (9):954-660. Forte AJ, Boczar D, Huayllani MT, Lu X, McLaughlin SA: Sympathetic Nerve Block in Lymphedema Treatment: A Systematic Review . Cureus 2019, 11 (9):e5700. Salman AS, Abbas DN, Elrawas MM, Kamel MA, Mohammed AM, Abouel Soud AH, Abdelgalil AS: Postmastectomy pain syndrome after preoperative stellate ganglion block: a randomized controlled trial . Minerva Anestesiol 2021, 87 (7):786-793. Soecknick S: Stellate ganglion block with procaine in breast cancer survivors with hot flashes and sleep disturbances undergoing Endocrine Therapy . Medicine (Baltimore) 2024, 103 (2):e36848. Yang RZ, Li YZ, Liang M, Yu JJ, Chen ML, Qiu JJ, Lin SZ, Wu XD, Zeng K: Stellate Ganglion Block Improves Postoperative Sleep Quality and Analgesia in Patients with Breast Cancer: A Randomized Controlled Trial . Pain Ther 2023, 12 (2):491-503. Wei N, Chi M, Deng L, Wang G: Antioxidation Role of Different Lateral Stellate Ganglion Block in Isoproterenol-Induced Acute Myocardial Ischemia in Rats . Reg Anesth Pain Med 2017, 42 (5):588-599. Geng J, Wang J, Zhang Y, Song W, Zhu J, Chen J, Wu Z: The Effect of a Combined Modified Pectoral and Stellate Ganglion Block on Stress and Inflammatory Response in Patients Undergoing Modified Radical Mastectomy . Int J Breast Cancer 2022, 2022 :3359130. Tazreean R, Nelson G, Twomey R: Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements . J Comp Eff Res 2022, 11 (2):121-129. Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O: Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations . Plast Reconstr Surg 2017, 139 (5):1056e-1071e. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6178697","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435831034,"identity":"214c61ed-7014-4fc5-abcc-824affa021fe","order_by":0,"name":"Xuebing Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3RMWvCQBTA8Xc9eNOLWV9Q9CtEhCA4+FXuKLgVOmaQNnJiBhFX/RaOji2BTNdd6BI/gc3WoYPZLUncHO43vz+8dwfgOA8IB5ey0H/8vjD+uVDxvDnpgBqFZTIWJiUZFjZvTvqgomCfxCLdEgbnpWyxGHzMut6RpWe8PNYJgp+uVX0ikmziWcbAdGYnfewB269DfSLF4puQaWggOmmLEPJLQ4ISulXC0wyiV72SLRLCp2C/4lAYiqBdwtXb/lhWwuAzK5tT4y2DHYnqB9+U2Gaf5W887/vppj65QfeNO47jOP+6AufBQ+n19WvSAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Xuebing","middleName":"","lastName":"Wang","suffix":""},{"id":435831035,"identity":"55f0d537-192d-4768-905f-48b35cd942d0","order_by":1,"name":"Zhenqi liu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Zhenqi","middleName":"","lastName":"liu","suffix":""},{"id":435831036,"identity":"461e5a5f-76bf-4ac9-83fd-d6339dc2ce1f","order_by":2,"name":"Yong Pang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Pang","suffix":""}],"badges":[],"createdAt":"2025-03-07 13:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6178697/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6178697/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79577412,"identity":"7a869a6e-7321-4a4d-a0cd-dbadbdc43807","added_by":"auto","created_at":"2025-03-31 11:25:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93694,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6178697/v1/77f31f10d8e5a5d747c8bbfd.png"},{"id":81575579,"identity":"601da93f-72ed-4697-83c1-0a9996062362","added_by":"auto","created_at":"2025-04-28 17:31:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2585282,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6178697/v1/075caeb4-ca29-4689-bf73-652f87233678.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffect of ultrasound-guided stellate ganglion block combined with erector spinal plane block on postoperative recovery quality of breast cancer patients: a randomized controlled trial\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer, as the second most common cancer after lung cancer and also the most prevalent malignant tumor among women worldwide, has shown an increasing trend in its incidence in recent years, and the disease is one of the leading causes of cancer deaths among women worldwide[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although there are many treatment options for breast cancer, the main treatment choice for breast cancer remains surgery, with modified radical mastectomy (MRM) being the most common surgical treatment option today[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Because MRM is more invasive, most patients undergoing surgery experience acute postoperative pain, and if acute postoperative pain is not adequately controlled, it may even further evolve into chronic pain, resulting in post-mastectomy pain syndrome (PMPS), which can range from 20\u0026ndash;68%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This not only increases the difficulty of treatment, but also has a serious impact on the patient's postoperative recovery, increasing the incidence of postoperative complications, delaying wound healing, and prolonging the patient's hospitalization. Therefore, effective postoperative analgesic strategies are essential to promote patients' postoperative recovery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eESPB has been gradually used in breast cancer surgery because it is simple, safe, easy to perform, and can provide good postoperative analgesia to patients, and its analgesic effect is equivalent to thoracic paravertebral nerve block (TPVB), which is considered to be an effective alternative to TPVB in breast cancer surgery[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The stellate ganglion block, which covers a wide range of indications, plays an important role in the treatment, diagnosis, and prognostic evaluation of a variety of diseases, and has also been gradually used in breast cancer surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although studies by Yang[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]and Wiech[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]have shown that both SGB and ESPB can improve the quality of postoperative recovery in breast cancer patients, respectively, there is a lack of evidence that the combination of the two is more effective in improving the quality of postoperative recovery in patients.\u003c/p\u003e \u003cp\u003e The purpose of this study was to compare whether the combination of ultrasound-guided SGB and EPSB is more effective than EPSB alone in improving the quality of postoperative recovery in women undergoing unilateral MRM.\u003c/p\u003e"},{"header":"Materials and method","content":"\u003cp\u003e\u003cstrong\u003e1.1 Study subjects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis experiment has been approved by the Ethics Committee of the Affiliated Hospital of Chuanbei Medical College (Approval No. 2024ER329-1), and the patients and their families signed the informed consent form before the experiment.90 surgical patients who underwent unilateral modified radical mastectomy from June 2024 to October 2024 at the Affiliated Hospital of Chuanbei Medical College were selected, and divided into the combined block group (45 cases) and the control group (45 cases).\u003c/p\u003e\n\u003cp\u003eInclusion Criteria: Breast cancer patients scheduled for elective unilateral MRM were screened and recruited during preoperative evaluation, and preoperative education was routinely provided to recruited patients. The inclusion criteria were as follows: a. Patients with a clear preoperative diagnosis who underwent unilateral MRM; b. Age 18-65 years; c. Class I or II according to the American Society of Anesthesiologists Physical Condition Assessment System.\u003c/p\u003e\n\u003cp\u003eExclusion Criteria: a. Preoperative combination of serious heart, liver, kidney and other dysfunctional diseases; b. Allergy to the local anesthetics used in the study, infection at the puncture site, abnormal coagulation function; c. Cognitive function, hearing and speech disorders, history of mental illness, difficulty in communicating, or difficulty in cooperating with the patients with mental disorders.\u003c/p\u003e\n\u003cp\u003eWithdrawal Criteria:(i) Failure of SGB and/or ESPB; (ii) Patients with adverse reactions to the drugs used or other reasons that require stopping the study midway.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eRandomization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA series of random sequences were generated by an online randomizer and sealed in opaque envelopes by staff not involved in this study. All participants were randomized in a 1 : 1 ratio into a combined block group (SE group) and a control group (E group). All patients, anesthesiologists, and outcome assessors were unaware of the study group assignment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAnesthesia interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SE group received a stellate ganglion block combined with a planar block of the erector spinae muscle 15 minutes before induction of anesthesia, and an attending anesthesiologist familiar with ultrasound-guided nerve blocks used an ultrasound machine to locate the longissimus cervicis muscle at the level of the C6 cervical vertebrae. After local anesthesia was administered to the correct puncture site, an in-plane needle approach was performed to penetrate the muscle surface. After confirming that there was no cerebrospinal fluid, blood, or gas on aspiration, SGB was performed by injecting 6 ml of 0.25% ropivacaine hydrochloride. The presence of Horner\u0026apos;s syndrome on the side of the block confirmed the success of SGB. Then the patient was placed in the lateral position, with the affected side facing upward, and the transverse plane block technique was used, with the probe placed in the T5 transverse process and the probe moved 2 cm to the affected side, and the ultrasound image showed the trapezius, rhomboid, erector spinae, and T5 transverse process in sequence, and the in-plane approach was performed up to the T5th transverse process, and 20 ml of 0.375% loperamide hydrochloride was injected after being returned to the bloodless side prior to each injection. After successful implementation of the block, the patient\u0026apos;s vital signs were closely monitored to prevent any complications.\u003c/p\u003e\n\u003cp\u003eIn the control group (Group E), a planar block of the erector spinae muscle was performed only before the induction of anesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAnesthesia procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups of patients were operated with intravenous inhalation combined general anesthesia, and anesthesia induction and tracheal intubation were performed by the same anesthesiologist. Upon entering the operating room, patients underwent routine examinations, including monitoring of heart rate (HR), mean arterial pressure (MAP), pulse oximetry (SpO2) and electrocardiogram (ECG). Peripheral intravenous fluid access was established. For induction of anesthesia, midazolam 0.05 mg/kg, sufentanil 0.3\u0026mu;g/kg, propofol 1.5-2.0 mg/kg, and atracurium benzenesulfonate 0.15 mg/kg were given in sequence, and while slowly injecting the drugs, the patient\u0026apos;s blood pressure, heart rate, electrocardiogram, and changes in BIS were closely observed, and attention was paid to the patient\u0026apos;s consciousness and respiration, so that assisted ventilation was given in a timely manner, and after the inotropic drugs had taken full effect, the patient\u0026apos;s blood pressure, heart rate, electrocardiogram and changes in BIS were monitored using visualization. After the inotropic medication was fully effective, tracheal intubation was carried out using a visual laryngoscope. After intubation, mechanical ventilation was started, and the parameters of the ventilator were adjusted to a tidal volume of 6-8 ml/kg, a respiratory rate of 12-16 breaths/min, an end-expiratory partial pressure of carbon dioxide of 35-45 mmHg, and a respiratory ratio of 1:1. During the operation, the depth of anesthesia was maintained by inhalation of 2.0% sevoflurane and pump injection of remifentanil hydrochloride, and 2mg of atracurium benzenesulfonate was given intermittently according to the needs of the operation. The pumping rate of remifentanil was appropriately adjusted according to the changes in BIS value, blood pressure and heart rate to ensure that the patient was in an appropriate state of anesthesia. The principle of fluid replenishment was 6-8ml/kg/h, mainly crystalloid. During the operation, adequate oxygenation and hemodynamic stability were maintained. Systolic blood pressure lower than 20% of the preoperative basal value or lower than 90mmHg was regarded as hypotension, and 6mg of ephedrine was injected intravenously, while systolic blood pressure higher than 20% of the basal value or higher than 180mmHg was lowered by injecting 15mg of urocortisol intravenously, and the heart rate of the patient was maintained at between 50-100 beats/min with the use of atropine or esmolol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAwakening from anesthesia and postoperative analgesia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdministration of atracurium benzenesulfonate injection was discontinued 40 minutes before the end of the procedure, and a final dose of 10\u0026mu;g sufentanil was administered and remifentanil was discontinued 30 minutes before the end of the procedure. Sevoflurane was discontinued 15 minutes before the end of the procedure and the patient was given 10-15 minutes of pure oxygen inhalation to help clean the lungs. Suction care was performed and criteria for extubation were confirmed before removal of the endotracheal tube. Patients were admitted to the post anesthesia care unit (PACU) for routine monitoring and transferred to the ward after meeting criteria for discharge from the PACU. Patients in both groups received postoperative intravenous self-controlled analgesia (PCIA). The analgesic regimen consisted of 150 ug of sufentanil, 8 mg of Butorphanol, and 5 mg of Tolansetron diluted in saline to 150 mL.The PCIA parameters were determined as follows:a background infusion rate of 1.5 mL/h, a single dose of 0.5 mL, and a lockout time of 15 minutes for a total duration of 24 hours. If the postoperative VAS score on return to the room was \u0026gt;7, the attending nurse could administer a rescue dose of oxycodone (5 mg).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.6\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eOutcome measurement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the assessment of the patients using the Chinese version of the Global Quality of Recovery Rating Scale QoR-15.The QoR-15 scale assesses the patients\u0026apos; postoperative physical recovery from five aspects totaling 15 questions, namely pain, physical comfort, physical independence, psychological support, and emotional state.The score of the QoR-15 ranges from 0 to 150, with higher scores suggesting better quality of postoperative recovery[10]. Secondary regressions included recording the dose of opioids used during general anesthesia, general information; a team member who did not know the subgroups recorded postoperative patients\u0026apos; VAS scores at 2h, 6h, 12h, and 24h, the incidence of postoperative adverse reactions (e.g., nausea, vomiting, itching, etc.), the time to the first self-administered analgesia, number of effective presses on the analgesic pump at 24h, number of cases of additional remedies for analgesia, the time to the first time of getting out of bed, the time to the first postoperative total hospitalization time surgery and the incidence of chronic pain in the second three months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.7\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our preliminary study, the mean standard deviation (SD) of the QoR-15 scores in the postoperative combined block group and the control group were 121.2 \u0026plusmn; 6.3 and 111.2 \u0026plusmn; 6.5, respectively, and setting the type I error rate of \u0026alpha; = 0.05 and the test efficacy of \u0026beta; = 0.9, a minimum of 34 samples in each group was calculated using the GPower3.1 software, taking into account the 20% loss to followup rate, and a minimum of 34 samples in each group were required. 45 patients were finally recruited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.8\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS 27.0 statistical software. Continuous data were expressed as mean standard deviation \u003cimg src=\"data:image/png;base64,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\"\u003e\u0026nbsp;and t-tests were used for comparisons between groups. Within-group comparisons at different time points were performed using repeated measures ANOVA. Categorical data were expressed as proportions (%), and comparisons between groups were performed using the chi-square test and exact probability method. p\u0026lt; 0.05 was statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eComparison of general information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 90 cases were collected from June 2024 to October 2024, of which none withdrew from the study (study flow chart shown in Fig.1). Patient demographic characteristics, including weight, height, age, admission mean arterial pressure (MAP), heart rate (HR), and ASA classification, did not differ significantly between the two groups. Differences in anesthesia induction time, anesthesia maintenance time, anesthesia recovery time, and operation time were not statistically significant (P\u0026gt; 0.05) between the two groups, as shown in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1 Demographic profile of two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e49\u0026plusmn;7.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e48.47\u0026plusmn;7.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.742\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eASA grade I/II, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e33（73%/12(27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e31(69%)/14(31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e156.07\u0026plusmn;5.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e156.04\u0026plusmn;6.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e59.40\u0026plusmn;7.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e57.98\u0026plusmn;7.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.374\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMAP（mmHg）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e93.14\u0026plusmn;11.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e94.28\u0026plusmn;10.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eHR（times/min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e77.20\u0026plusmn;8.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e74.67\u0026plusmn;7.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.134 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAnesthesia induction time\u0026nbsp;（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e5.89\u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5.82\u0026plusmn;1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.791\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAnesthesia maintenance time\u0026nbsp;（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e139.00\u0026plusmn;8.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e140.81\u0026plusmn;11.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAnesthesia recovery time\u0026nbsp;（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e18.69\u0026plusmn;2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e19.11\u0026plusmn;2.44\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.378\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSurgical time\u0026nbsp;（min）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e124.98\u0026plusmn;9.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e126.78\u0026plusmn;12.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.436\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol\u0026nbsp;\u0026lowast; represents the comparison between the SE group and the E group, with P \u0026lt; 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. ASA: American society of Anesthesiologist physical status. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of the quality of postoperative recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the control group, the QoR-15 score was significantly higher in the SE group on the first postoperative day (P \u0026lt; 0.05), and the difference in the QoR-15 score on the first postoperative day had exceeded the reported Minimal clinically important difference (MCID), which means that an increase in the QoR-15 of 6.0 points if it is equal to or more than 6.0 points implies clinically important improvement[11]. As shown in Table 2.\u003c/p\u003e\n\u003cp\u003eTable2 Comparison of QoR-15 scores among two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePreoperative QoR-15 scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e136.56\u0026plusmn;2.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e136.60\u0026plusmn;2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eQoR-15 scores on POD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e121.82\u0026plusmn;6.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e113.40\u0026plusmn;6.16 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol\u0026nbsp;\u0026lowast;\u0026nbsp;represents the comparison between the SE group and the E group, with P \u0026lt; 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. POD1, postoperative day 1, QoR-15, quality of recovery-15.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of intraoperative opioid use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen comparing and analyzing the amount of intraoperative sufentanil used in the two groups, no significant difference was observed (P \u0026gt; 0.05). In contrast, compared with the control group, the demand for intraoperative remifentanil in the SE group was significantly lower, which was statistically significant (P \u0026lt; 0.05). As shown in Table 3.\u003c/p\u003e\n\u003cp\u003eTable 3 Comparison of Sufentanil dose and Remifentanil dose among two groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eSufentanil dose/ug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e27.87\u0026plusmn;2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e27.36\u0026plusmn;2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003eRemifentanil dose/ug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e487.11\u0026plusmn;26.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e570.67\u0026plusmn;31.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean\u0026plusmn;SD. The symbol\u0026nbsp;\u0026lowast;\u0026nbsp;represents the comparison between the SE group and the E group, with P \u0026lt; 0.05.The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of the use of postoperative analgesic pump\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the control group, the SE group had a prolonged time to the first postoperative analgesic pump press and a lower total number of 24-h analgesic pump presses (P \u0026lt; 0.05), indicating that the SE group had better analgesia than the E group in the postoperative period. No postoperative rescue analgesia was performed in both groups. As shown in Table 4.\u003c/p\u003e\n\u003cp\u003eTable 4 Comparison of the first postoperative analgesic pump press and number of 24h analgesic pump presses among two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eFirst ACP time/h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e11.67\u0026plusmn;2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e9.04\u0026plusmn;2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e24h APC/times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e7.64\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e9.98\u0026plusmn;2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol\u0026nbsp;\u0026lowast; represents the comparison between the SE group and the E group, with P \u0026lt; 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. APC: analgesic pump compressions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of postoperative VAS scores at rest and during activity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the control group, the SE group had lower VAS scores in the resting and active states at 12h and 24h postoperatively, and the difference was statistically significant (P \u0026lt; 0.05); however, the difference in VAS scores between the two groups was not statistically significant in the resting and active states at 2h and 6h postoperatively (P \u0026gt; 0.05). As shown in Tables 5 and 6.\u003c/p\u003e\n\u003cp\u003eTable 5 Comparison of postoperative VAS scores at rest between the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative 2h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e0.78\u0026plusmn;0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.91\u0026plusmn;0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative 6h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e1.13\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.31\u0026plusmn;0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative 12h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e1.53\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.80\u0026plusmn;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.018\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003ePostoperative 24h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e1.02\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.51\u0026plusmn;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol\u0026nbsp;\u0026lowast;\u0026nbsp;represents the comparison between the SE group and the E group, with P \u0026lt; 0.05. The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group.\u003c/p\u003e\n\u003cp\u003eTable 6 Comparison of VAS scores at postoperative activities between the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePostoperative 2h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e1.24\u0026plusmn;0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.36\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePostoperative 6h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e1.82\u0026plusmn;0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.04\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePostoperative 12hVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e2.42\u0026plusmn;0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e3.16\u0026plusmn;0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePostoperative 24h VAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003e1.80\u0026plusmn;0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.31\u0026plusmn;0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol \u0026lowast; represents the comparison between the SE group and the E group, with P \u0026lt; 0.05，The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of other postoperative data between the two groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with the control group, the SE group demonstrated an early time of first out-of-bed activity and a short total postoperative hospitalization time after surgery, with statistically significant differences (P \u0026lt; 0.05), and there was no significant difference between the two groups in the incidence of postoperative adverse reactions (including nausea and vomiting, skin itching, vertigo, and so on), and the incidence of chronic pain in the three-month postoperative period (P \u0026gt; 0.05). As shown in Table 7.\u003c/p\u003e\n\u003cp\u003eTable 7 comparison of other postoperative data between the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eProject\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eSE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eE group (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eTime to FPD/h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e21.56\u0026plusmn;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e23.09\u0026plusmn;1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eTotal postoperative hospitalization/d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e5.62\u0026plusmn;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e6.42\u0026plusmn;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e＜0.001\u0026lowast;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIncidence of PAR/n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3(6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e8(17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIncidence of PCP at 3 months /n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e17(37.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e21(46.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData is represented as mean \u0026plusmn;SD. The symbol \u0026lowast; represents the comparison between the SE group and the E group, with P \u0026lt; 0.05，The SE group refers to the stellate ganglion block combined with erector spinal block; The E group refers to the control group. FPD: first postoperative bedtime; PAR: postoperative adverse reactions; PCP: Postoperative chronic pain.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main hypothesis of our study, that breast cancer patients undergoing unilateral MRM using SGB\u0026thinsp;+\u0026thinsp;ESPB achieve better quality of postoperative recovery, was confirmed according to the results of the study. Compared with the control group, the overall postoperative QoR-15 score in the SE group was 8 points higher than that in the control group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which exceeded the MCID reported by Myles, suggesting that the enhancement of the quality of postoperative recovery by SGB in combination with ESPB was superior to that of ESPB alone. However, the QoR-15 scores of the control group differed from those previously derived by Yao[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], which may be related to biological, psychological, and social factors of geographic and inter-individual variability[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMRM, due to its surgical scope involving extensive chest wall tissues and complex nerve injuries, can often result in patients experiencing different degrees of acute or chronic pain after surgery, which is detrimental to the postoperative recovery process and postoperative quality of life[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In recent years, with the development and promotion of the concept of accelerated recovery after surgery (ERAS), regional anesthesia block techniques have been gradually applied to various types of breast cancer surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies have shown[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] that regional anesthesia block can reduce patients' postoperative pain as well as help to reduce surgical stress, which has a positive impact on patients' postoperative recovery.\u003c/p\u003e \u003cp\u003eAccording to a meta-analysis[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], regional anesthetic blocks commonly used in breast cancer surgery include paravertebral nerve block, thoracic nerve-2 block, anterior serratus plane block, erector spinae plane block, rhomboid intercostal block, and local anesthesia. However, compared with the erector spinae plane block, other anesthesia techniques show some limitations in their application. For example, paravertebral nerve block can lead to complications such as hypotension, bradycardia, and local anesthetic toxicity; after thoracic nerve block, the diffusion of local anesthetic in the surgical area can lead to an increase in electrical resistance, which interferes with surgical procedures; and local anesthesia is not as effective as regional anesthesia in terms of analgesic effect [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eESPB was firstly proposed as a novel anesthesia technique by Forero et al. for the first time in 2016, ESPB not only blocks the ventral and dorsal branches of spinal nerve roots, but also blocks the fiber traffic branches containing connections between the sympathetic ganglion and spinal nerves, which produces analgesic effects on the trunk and viscera. Numerous studies[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] have shown that ESPB is effective in providing analgesia after breast cancer surgery, reducing the amount of opioids used in patients undergoing breast cancer surgery as well as improving the quality of postoperative recovery. However, Forero et al. also suggested that ESPB of the T5 transverse process on one side only blocked the innervation area of the ipsilateral T3-T9 spinal nerves [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], whereas the innervation area of the breast was the lateral and anterior cutaneous branches of the T2-T6 spinal nerve branches as well as several branches of the supraclavicular nerves, and the analgesic effect of the ESPB was smaller than that of thoracic nerve block[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], which suggested that ESPB could not provide adequate regional analgesia in breast cancer surgery. adequate regional analgesia.\u003c/p\u003e \u003cp\u003eSGB has not only demonstrated significant efficacy in the treatment of painful disorders, but also for non-painful disorders[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. SGB can regulate and attenuate neuropathic pain by promoting vasodilation at the surgical site, accelerating the clearance of inflammatory mediators, and inhibiting the transfer of leukocytes to the site of inflammation, reducing the production of inflammatory mediators[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Some studies have shown[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] that preoperative SGB can enhance sleep quality, treat hot flushes, improve symptoms of lymphedema, reduce the incidence of postoperative pain and PMPS in patients undergoing breast cancer surgery, and recover gastrointestinal function better in the postoperative period, improving the quality of postoperative recovery in patients. In conclusion, we believe that SGB combined with ESPB can produce better postoperative analgesia and higher quality of postoperative recovery for patients.\u003c/p\u003e \u003cp\u003eIn recent years, with the continuous development of ultrasound technology, ultrasound-guided regional anesthesia block technology has become increasingly mature and widely used in clinical practice, and the safety and precision of ultrasound-guided SGB and ESPB have been greatly improved compared with the traditional technology, and all of the experiments were performed under ultrasound guidance. The right SGB was chosen for this experiment because it showed more significant antioxidant effects and was able to reduce the concentration of catecholamines in the blood, which in turn reduced the stress response[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, postoperative VAS scores, intraoperative opioid requirements, and postoperative analgesic pump requirements were lower in the SE group compared to the control group, demonstrating longer duration of analgesia. This result is also supported by the findings of Geng [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] et al. who reported that SGB combined with thoracic nerve block was more effective in relieving stress and reducing acute postoperative pain than single thoracic nerve block, and that the analgesic effect of SGB could be sustained for up to 12 h. This is in line with the conclusion that SGB provides effective analgesia, as reported in several previous clinical trials.\u003c/p\u003e \u003cp\u003eEarly activity is an important component of ERAS and plays an important role in reducing the risk of postoperative complications, shortening the length of hospitalization, and reducing the financial burden on patients[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Temple-Oberle[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]et al. concluded that early activity within 24h postoperatively plays a positive role in the postoperative recovery of patients undergoing breast surgery. One of the main reasons for impaired early postoperative activity is that surgery leads to inflammation and other disruptions of homeostasis in the body [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our study showed that compared with the control group, the SE group had an earlier time to first get out of bed and a shorter total postoperative hospital stay, which indicated that SGB combined with ESPB could more effectively eliminate the adverse effects of surgery, accelerate the recovery process of patients' early postoperative activities, and promote the overall recovery of the patients; however, the two groups of patients did not show a significant difference in the incidence of postoperative adverse reactions.\u003c/p\u003e \u003cp\u003eNo conclusive evidence was found in our study to support the hypothesis that SGB reduces PMPS in patients undergoing breast cancer surgery. The two groups of patients did not demonstrate a significant difference in the incidence of postoperative chronic pain, a result that diverges from the findings of previous studies, probably because the results of our study were the incidence of PMPS at three months postoperatively, which is a relatively short period of time of observation, and does not effectively reflect the long-term effect of SGB on the incidence of PMPS.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, we selected only female patients who underwent MRM, with a single type of surgery and gender, and a relatively small sample size. Second, we only recorded the incidence of chronic pain at three months postoperatively and did not compare the severity of chronic pain occurrence. In addition, certain factors, such as the quality of postoperative sleep, recovery of postoperative gastrointestinal function, and assessment of postoperative lymphedema symptoms were not recorded or compared in this study. In future studies, for a more scientifically designed and more comprehensive assessment of the effectiveness of ultrasound-guided SGB combined with ESPB in breast cancer surgery, we recommend more multicenter studies that include a more diverse group of participants, including male patients and patients undergoing surgery for different types of breast cancer, as well as a comprehensive documentation of the insufficient parts of the current study for a more comprehensive and in-depth comparative analysis\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn breast cancer patients undergoing MRM, the combined block group was more effective than ESPB alone in reducing opioid use and lowering postoperative VAS scores, improving the quality of patients' postoperative recovery. The combined block approach also helped promote early activity and shorter hospital stays.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSGBStellate ganglion block\u003c/p\u003e\n\u003cp\u003eESPB Erector spinae plane block\u003c/p\u003e\n\u003cp\u003eMRM Modified radical mastectomy\u003c/p\u003e\n\u003cp\u003eQoR-15 Quality of recover-15\u003c/p\u003e\n\u003cp\u003eVAS Visual analogue scale\u003c/p\u003e\n\u003cp\u003ePMPS Post-mastectomy pain syndrome,\u003c/p\u003e\n\u003cp\u003eASA American society of anesthesiologists\u003c/p\u003e\n\u003cp\u003eTPVB Thoracic paravertebral nerve block\u003c/p\u003e\n\u003cp\u003eHR Heart rate\u003c/p\u003e\n\u003cp\u003eMAP Mean arterial pressure\u003c/p\u003e\n\u003cp\u003eBIS Bispectral index\u003c/p\u003e\n\u003cp\u003eSpO2 Pulse oxygen saturation\u003c/p\u003e\n\u003cp\u003eECG Electrocardiogram\u003c/p\u003e\n\u003cp\u003ePACU Post-anesthetic care unit\u003c/p\u003e\n\u003cp\u003ePCIA Patient controlled intravenous analgesia\u003c/p\u003e\n\u003cp\u003eMCID Minimal clinically important difference\u003c/p\u003e\n\u003cp\u003ePOD1 postoperative day 1\u003c/p\u003e\n\u003cp\u003eAPC analgesic pump compressions\u003c/p\u003e\n\u003cp\u003eFPD first postoperative bedtime\u003c/p\u003e\n\u003cp\u003ePAR postoperative adverse reactions\u003c/p\u003e\n\u003cp\u003ePCP Postoperative chronic pain\u003c/p\u003e\n\u003cp\u003eERAS enhanced recovery after surgery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval by Medical Ethics Committee of Affiliated Hospital of North Sichuan Medical College (2024ER329-1) on 22/05/2024, with registration on Clinicaltrials. \u0026nbsp;Chinese Clinical Trial Registry (ChiCTR2400085892) on 20/06/2024. Written informed consent was obtained from every patient by the investigators, and that this work was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during this study are not publicly available due to institutional policy on data confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXW: Conceptualization, methodology, investigation, formal analysis, writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft, review, and editing. ZL: Conceptualization, methodology, formal analysis, writing\u0026nbsp;\u0026ndash;\u0026nbsp;review and editing. YP: Conceptualization, methodology, investigation, formal analysis, writing\u0026nbsp;\u0026ndash;\u0026nbsp;review and editing, supervision.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAffiliated Hospital of North Sichuan Medical College, Nanchong,Dept of Anesthesiology, Affiliated Hospital of North Sichuan Medical College\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: \u003cstrong\u003eGlobal cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries\u003c/strong\u003e. \u003cem\u003eCA Cancer J Clin\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e74\u003c/strong\u003e(3):229-263.\u003c/li\u003e\n \u003cli\u003eHuang S, Yang Q, Zheng X, Chow KM, Wu J, Zhu J: 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\u003cli\u003eTazreean R, Nelson G, Twomey R: \u003cstrong\u003eEarly mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements\u003c/strong\u003e. \u003cem\u003eJ Comp Eff Res\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e11\u003c/strong\u003e(2):121-129.\u003c/li\u003e\n \u003cli\u003eTemple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O: \u003cstrong\u003eConsensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations\u003c/strong\u003e. \u003cem\u003ePlast Reconstr Surg\u0026nbsp;\u003c/em\u003e2017, \u003cstrong\u003e139\u003c/strong\u003e(5):1056e-1071e.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"stellate ganglion block, erector spinae plane block, stellate ganglion block combined with erector spinae plane block, quality of postoperative recovery, breast cancer","lastPublishedDoi":"10.21203/rs.3.rs-6178697/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6178697/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eThere are many reports demonstrating that regional anaesthesia improves the quality of postoperative recovery in patients undergoing breast cancer surgery; however, the enhancement of the quality of postoperative recovery by a combined block of regional anaesthesia has rarely been investigated. We compared whether stellate ganglion block (SGB) combined with erector spinal plane block (ESPB) was more effective than ESPB alone in improving the quality of postoperative recovery in female patients undergoing unilateral modified radical mastectomy (MRM) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Ninety female patients were selected for elective proposed unilateral modified radical mastectomy and randomly divided into combined block group (SE group) and control group (E group), with 45 cases in each group. The same anesthetic drugs were used for induction and maintenance in both groups, and ultrasound-guided right stellate ganglion block combined with a plane block of the affected erector spinae muscle was performed 15 min before induction of anesthesia in the SE group, while only a plane block of the affected erector spinae muscle was performed in the E group. QoR-15 scores on the first postoperative day and postoperative visual analog scores (VAS) at different time points were observed in both groups; intraoperative opioid use was observed in both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e QoR-15 scores on the first postoperative day were significantly improved in the SE group (122.91 ± 6.15) compared with the E group (114.80 ± 7.01) (P \u0026lt; 0.05); the SE group showed lower VAS scores than the E group at 12h and 24h postoperatively in the resting (1.53 ± 0.50, 1.02 ± 0.69; 1.80 ± 0.54, 1.51 ± 0.62, respectively) and active (respectively 2.42±0.49, 1.80±0.58; 3.16±0.52, 2.31±0.46) states(P\u0026lt;0.05); intraoperative remifentanil use was lower in the SE group (487.11±26.59ug, 570.67±31.29ug, respectively, P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e After unilateral MRM, the combined block group was more effective than ESPB alone in reducing opioid consumption and lowering postoperative VAS scores, improving the quality of patients' postoperative recovery.\u003c/p\u003e","manuscriptTitle":"Effect of ultrasound-guided stellate ganglion block combined with erector spinal plane block on postoperative recovery quality of breast cancer patients: a randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 11:25:17","doi":"10.21203/rs.3.rs-6178697/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3901da1b-fe23-4095-962a-0e0b90c0fcbd","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T17:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-31 11:25:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6178697","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6178697","identity":"rs-6178697","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}