[Combined general-epidural anesthesia compared to general anesthesia: a systematic review and meta-analysis of morbidity and mortality and analgesic efficacy in thoracoabdominal surgery]

Is there a relationship between two different anesthetic methods and postoperative length of stay during radical resection of malignant esophageal tumors in China?: a retrospective cohort study

BACKGROUND

Data providing a relationship between the anesthetic method and postoperative length of stay (PLOS) is limited. We aimed to investigate whether general anesthesia alone or combined with epidural anesthesia might affect perioperative risk factors and PLOS for patients undergoing radical resection of malignant esophageal tumors.

METHODS

The study retrospectively analyzed the clinical data of 680 patients who underwent a radical esophageal malignant tumor resection in a Chinese hospital from January 01, 2010, to December 31, 2020. The primary outcome measure was PLOS, and the secondary outcome was perioperative risk-related parameters that affect PLOS. The independent variable was the type of anesthesia: general anesthesia (GA) or combined epidural-general anesthesia (E-GA). The dependent variable was PLOS. We conducted univariate and multivariate logistic regression and propensity score matching to compare the relationships of GA and E-GA with PLOS and identify the perioperative risk factors for PLOS. In this cohort study, the confounders included sociodemographic data, preoperative chemotherapy, coexisting diseases, laboratory parameters, intraoperative variables, and postoperative complications.

RESULTS

In all patients, the average PLOS was 19.85 ± 12.60 days. There was no significant difference in PLOS between the GA group and the E-GA group either before or after propensity score matching (20.01 days ± 14.90 days vs. 19.79 days ± 11.57 days, P = 0.094, 18.09 ± 9.71 days vs. 19.39 ± 10.75 days, P = 0.145). The significant risk factors for increased PLOS were lung infection (β = 3.35, 95% confidence interval (CI): 1.54-5.52), anastomotic leakage (β = 25.73, 95% CI: 22.11-29.34), and surgical site infection (β = 9.39, 95% CI: 4.10-14.68) by multivariate regression analysis. Subgroup analysis revealed a stronger association between PLOS and vasoactive drug use, blood transfusions, and open esophagectomy. The results remained essentially the same (stable and reliable) after subgroup analysis.

CONCLUSIONS

Although there is no significant association between the type of anesthesia(GA or E-GA) and PLOS for patients undergoing radical esophageal malignant tumor resection, an association between PLOS and lung infection, anastomotic leakage, and surgical site infection was determined by multivariate regression analysis. A larger sample future study design may verify our results.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies

BACKGROUND

To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA).

METHODS

The databases of PubMed, Google scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV).

RESULTS

Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I² = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I² = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I² = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications.

CONCLUSION

This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.

Distribution of contrast medium epidurally injected at thoracic and lumbar vertebral segments

The epidural distribution of iohexol (0.2 ml/kg) administered at thoracic vertebrae (Thoracic group) and lumbar vertebrae (Lumbar group) was compared by computed tomographic (CT) epidurography in dogs. The total spread of iohexol was similar between the 2 groups upon reaching a similar cranial level. The maximal CT values were higher at the C7/T1 and T4/T5 levels in Thoracic group, but they were higher at the T13/L1 and L4/L5 levels in Lumbar group (P<0.05). This result suggests that the distribution pattern of the drug administered epidurally at thoracic vertebrae and lumbar vertebrae is different in dogs.

Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial

BACKGROUND

Intravenous (IV) fluid administration is an essential part of postoperative care. Some studies suggest that a restricted post-operative fluid regime reduces complications and postoperative hospital stay after surgery. We investigated the effects of postoperative fluid restriction in surgical patients undergoing major abdominal surgery.

METHODS

In a blinded randomized trial, 62 patients (ASA I-III) undergoing elective major abdominal surgical procedures in a university hospital were allocated either to a restricted (1.5 L/24 h) or a standard postoperative IV fluid regime (2.5 L/24 h). Primary endpoint was length of postoperative hospital stay (PHS). Secondary endpoints included postoperative complications and time to restore gastric functions.

RESULTS

After a 1-year inclusion period, an unplanned interim analysis was made because of many protocol violations due to patient deterioration. In the group with the restricted regime we found a significantly increased PHS (12.3 vs. 8.3 days; p = 0.049) and significantly more major complications: 12 in 30 (40%) vs. 5 in 32 (16%) patients (Absolute Risk Increase: 0.24 [95%CI: 0.03 to 0.46], i.e. a number needed to harm of 4 [95%CI: 2-33]). Therefore, the trial was stopped prematurely. Intention to treat analysis showed no differences in time to restore gastric functions between the groups.

CONCLUSION

Restricted postoperative IV fluid management, as performed in this trial, in patients undergoing major abdominal surgery appears harmful as it is accompanied by an increased risk of major postoperative complications and a prolonged postoperative hospital stay.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16719551.