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Ekramy M Abdelghafar,1 Ahmed H Othman,2 Mahmoud Salem Soliman,3 Ayman Kilany,4 Mohammed H Shaaban,5 Ehab H Shaker1 1Department of Anesthesia, ICU And Pain Relief, National Cancer Institute, Cairo University, Cairo, Egypt; 2Department of Anesthesia, ICU and Pain Relief, South Egypt Cancer Institute, Assiut University, Assiut, Egypt; 3Department of Anesthesia, Critical Care and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt; 4Department of Research on Children with Special Needs, National Research Center, Cairo, Egypt; 5Department of Diagnostic & Interventional Radiology, Faculty of Medicine, Cairo University, Cairo, EgyptCorrespondence: Ehab H ShakerDepartment of Anesthesia and Pain Relief, National Cancer Institute, Cairo University, Cairo, EgyptTel +2-01222438820Email ehabhanafy2006@yahoo.comBackground: Superior hypogastric neurolytic block is performed to block visceral pelvic pain. This could be performed through the anterior approach guided by CT or ultrasound and through a posterior approach, guided by fluoroscopy or CT.Methods: Sixty adult patients with severe visceral pelvic pain (VAS> 70 mm) were randomly divided into two groups. Group S: SHP block was done ultrasound guided using the anterior approach and confirmed by fluoroscopy. Group F: SHP block was done fluoroscopic guided using the posterior oblique approach. The VAS (visual analog scale), duration of the technique, time of X-ray exposure, patient satisfaction score, patient global impression of change (PGIC), quality of life score, and daily morphine consumption (mg/day) were measured pre-procedure and at the 1st, 4th, 8th, and 12th week after the procedure. In addition, any side effects of the procedure were recorded.Results: There was a significant difference in VAS between the two groups (P< 0.01) (better in group S). The quality of life score was improved from the pre-procedure in both groups (P< 0.05), and morphine consumption was significantly lower in group S than in group F (P< 0.05) at the 1st, 4th, and 8th week and not significant at the 12th week. The two groups show a statistically significant difference as regards the duration of the procedure and X-ray exposure (P< 0.01). There was a statistically significant difference in the satisfactory score between the two groups at the 1st, 4th, 8th, and 12th week (P< 0.01). As regards the PGIC score, there was no statistically significant difference between the two groups (P> 0.05). In group S, no back pain was reported, while 11 patients of group F complained from post-procedure back pain (P< 0.001).Conclusion: The anterior ultrasound guided SHPB aided by fluoroscopy is suggested to be more superior to the standard fluoroscopic guided technique in relieving pelvic cancer pain and decreasing morphine consumption.Keywords: superior hypogastric block, pelvic pain, fluoroscopy, ultrasound

Fatma A El Sherif,1 Ahmad M Abd El-Rahman,1 Ahmed H Othman,1 Samia A Shouman,2 Mervat M Omran,3 Nivin A Hassan,4 Sahar B Hassan,5 Ebrahim Aboeleuon6 1Anesthesia, ICU, and Pain Relief, South Egypt Cancer Institute, Assiut University, Assiut, Egypt; 2Cancer Biology, National Cancer Institute, Cairo University, Cairo, Egypt; 3Cancer Biology (Pharmacology and Experimental Oncology), National Cancer Institute, Cairo University, Cairo, Egypt; 4Cancer Biology (Pharmacology and Experimental Oncology), South Egypt Cancer Institute, Assuit University, Assiut, Egypt; 5Clinical Pharmacy, Faculty of Pharmacy, Assuit University, Assiut, Egypt; 6Surgical Oncology, South Egypt Cancer Institute, Assiut University, Assiut, EgyptCorrespondence: Ahmed H Othman Tel +20 1005098394Fax +20 88 2086609Email ahmadhothman@gmail.comBackground: Serratus anterior plane (SAP) block, a novel regional anesthetic procedure, involves the anterolateral chest wall. Opioid receptors have been found on peripheral nerve terminals, so morphine may have a local action.Objective: This work aimed at exploring the analgesic efficacy of morphine added to bupivacaine in SAPB in patients for whom modified radical mastectomy was conducted and whether it is a mere local effect.Methods: Forty female patients were planned to have modified radical mastectomy participated in the study. Patients were randomly divided into two groups; Control group (C): received ultrasound-guided serratus anterior plane block with 20 mL of bupivacaine hydrochloride 0.25%; Morphine group (M): received the same in addition to 10 mg morphine sulfate. Intra- and post-operative blood samples were taken for the assessment of morphine serum levels. All patients were assessed for VAS scores during rest and movement (VAS-R and VAS-M). Time to the first request and the total amount of the rescue analgesia were recorded.Results: In group M, Morphine was not detected in the plasma of all patients. Both VAS-R and VAS-M were significantly higher in group C than in group M (P< 0.001) and (P≤ 0.003), respectively. Time to the first request of rescue analgesia was 8.5 h in group C compared to 20 h in group M (P=0.005) with a median dose of acetaminophen consumption of 2 g in group C compared to 1 g in group M (P=0.006).Conclusion: Ten mg of morphine, when added to bupivacaine in SAPB, improved postoperative analgesia in patients to whom modified radical mastectomy was conducted. This effect seems to be attributed merely to local mechanisms.Registration: The registration number of this study is NCT02962024 at www.clinicaltrial.gov.Keywords: analgesic, morphine, bupivacaine, serratus anterior, modified radical mastectomy