Does Opioid Use Cause Angiogenesis and Metastasis?

Opioids and Cancer: Current Understanding and Clinical Considerations

Pain is one of the most common symptoms in patients with cancer. Pain not only negatively affects the quality of life of patients with cancer, but it has also been associated with reduced survival. Pain management is therefore a critical component of cancer care. Prescription opioids remain the first-line approach for the management of moderate-to-severe pain associated with cancer. However, there has been increasing interest in understanding whether these analgesics could impact cancer progression. Furthermore, epidemiological data link a possible association between prescription opioid usage and cancer development. Until more robust evidence is available, patients with cancer with moderate-to-severe pain may receive opioids to decrease suffering. However, future studies should be conducted to evaluate the role of opioids and opioid receptors in specific cancers.

Pain in Colorectal Surgery: How Does It Occur and What Tools Do We Have for Treatment?

Pain is a complex entity with deleterious effects on the entire organism. Poorly controlled postoperative pain impacts the patient outcome, being associated with increased morbidity, inadequate quality of life and functional recovery. In the current surgical environment with less invasive surgical procedures increasingly being used and a trend towards rapid discharge home after surgery, we need to continuously re-evaluate analgesic strategies. We have performed a narrative review consisting of a description of the acute surgical pain anatomic pathways and the connection between pain and the surgical stress response followed by reviewing methods of multimodal analgesia in colorectal surgery found in recent literature data. We have described various regional analgesia techniques and drugs effective in pain treatment, emphasizing their advantages and concerns. We have also tried to identify present knowledge gaps requiring future research. Our review concludes that surgical pain has peculiarities that make its management complex, implying a consistent, multimodal approach aiming to block both peripheral and central pain pathways.

Analgesic Modalities in Patients Undergoing Open Pancreatoduodenectomy-A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review explored the efficacy of different analgesic modalities and the impact on perioperative outcome in patients undergoing pancreatoduodenectomy.

METHODS

A systematic literature search was performed on PubMed, Embase, Web of Science, Scopus, and Cochrane Library Database using the PRISMA framework. The primary outcome was pain scores on postoperative day one (POD1) and postoperative day two (POD2). The secondary outcomes included length of hospital stay (LOS) and specific procedure-related complications.

RESULTS

Five randomized controlled trials and ten retrospective cohort studies were included in the systematic review. Studies compared epidural analgesia (EA), patient-controlled analgesia (PCA), continuous wound infiltration (CWI), continuous bilateral thoracic paravertebral infusion (CTPVI), intrathecal morphine (ITM), and sublingual sufentanil. The pain scores on POD1 (p < 0.001) and POD2 (p = 0.05) were higher in the PCA group compared with the EA group. Pain scores were comparable between EA and CWI plus PCA or CTPVI on POD1 and POD2. Pain scores were comparable between EA and ITM on POD1. The procedure-related complications and length of hospital stay were not significantly different according to the type of analgesia.

CONCLUSIONS

EA provided lower pain scores compared with PCA on the first postoperative day after pancreatoduodenectomy; the length of hospital stay and procedure-related complications were similar between EA and PCA. CWI and CTPVI provided similar pain relief to EA.

Mortality Trends of Gastrointestinal, Liver, and Pancreaticobiliary Diseases: A Hospital-Based Prospective Study in the Southeast of Iran

Background: Gastrointestinal (GI), liver, and pancreaticobiliary diseases, in addition to the high health care utilization, account for a significant proportion of disability and death in Iran. We aimed to assess the incidence of in-hospital mortality for the total GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman, Iran. Methods: In a cross-sectional study from May 2017 to April 2018, we collected the data of in-hospital death records due to GI, liver, and pancreaticobiliary diseases in all hospitals in Kerman city. GI and liver diseases were classified into three main categories: 1. Non-malignant GI diseases, 2. Non-malignant liver and pancreaticobiliary diseases, and 3. GI, liver, and pancreaticobiliary malignancies. All data were analyzed using SPSS software, version 22 (IBM). Results: Of 3427 in-hospital mortality, 269 (7.84%) deaths were due to GI, liver, and pancreaticobiliary diseases, of which 82 (30.48%) were related to non-malignant GI disorders, 92 (34.20%) to the non-malignant liver and pancreaticobiliary diseases, and 95 (35.31%) were associated with GI, liver and pancreaticobiliary malignancies. Most patients were male (62.08%), and the most common age was between 60-80 years (40.5%). GI bleeding occurred in 158 (58.73%) patients, and variceal bleeding was the most common cause (28.48%). Additionally, cirrhosis was reported in 41 out of 92 (44.56%), and hepatitis B virus (HBV) was the most common cause of cirrhosis among 17 out of 41 (41.46%). Conclusion: Our results show that gastric, colorectal, and pancreatic cancers and cirrhosis due to HBV were the most common causes of mortality associated with GI, liver, and pancreaticobiliary diseases in the hospitals of Kerman.

Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

Opium use and risk of bladder cancer: a multi-centre case-referent study in Iran

BACKGROUND

Bladder cancer (BC) is the 10th most common type of cancer worldwide and the fourth most common type of cancer in Iran. Opium use is considered as one of the risk factors for BC. We aim to assess the association between various parameters of opium use, which in Iran is mainly ingested or smoked in various forms, and the risk of BC.

METHOD

In this multi-centre case-referent study in Iran, 717 BC cases and 3477 referents were recruited to the study from May 2017 until July 2020. Detailed histories of opium use (duration, amount, frequency) and potential confounders were collected by trained interviewers. Multivariable unconditional logistic regression models were used to measure adjusted odds ratio (OR) and 95% confidence intervals (CI). The ORs were adjusted for age, gender, place of residence and pack-years of cigarette smoking.

RESULTS

Regular opium consumption was associated with an increased risk of BC (OR 3.5, 95% CI: 2.8, 4.3) compared with subjects who never used opium. Compared with continuous users, the risk decreased to one-third for those who stopped opium more than 10 years ago. The adjusted OR for those who used both crude opium (teriak) and opium juice was 7.4 (95% CI: 4.1, 13.3). There was a joint effect of opium and tobacco (OR for users of both opium and tobacco 7.7, 95% CI: 6.0, 9.7).

CONCLUSIONS

Regular opium use is associated with an approximately 4-fold risk for BC. The OR decreases along with the increasing time since stopping opium use.

Association between long-term opioid use and cancer risk in patients with chronic pain: a propensity score-matched cohort study

BACKGROUND

Whether long-term opioid use is an independent risk factor for cancer progression remains unclear. Therefore, we conducted a propensity score-matched population-based cohort study to compare cancer incidence between patients with chronic pain with and without opioid use.

METHODS

Data from January 2008 to December 2019 were obtained from the Taiwan National Health Insurance Research Database. Patients were categorised into two groups according to the presence or absence of opioid use, and matched at a 4:1 ratio. The incidence rate ratios for specific cancers were determined.

RESULTS

Propensity score-matching yielded 63 610 patients: 50 888 with opioid use (the opioid group) and 12 722 without (the non-opioid group). In a multivariate Cox regression analysis, the adjusted hazard ratio (95% confidence interval) for cancers in the opioid group compared with the non-opioid group was 2.66 (1.44-2.94; P<0.001). The incidence rate ratios (95% confidence interval) for lung, hepatocellular, colorectal, breast, prostate, head and neck, pancreatic, gastric, oesophageal, and ovarian cancers for the opioid group were 1.87 (1.41-2.43), 1.97 (1.56-2.50), 2.39 (1.87-3.03), 2.43 (1.75-3.33), 2.00 (1.35-3.03), 1.79 (1.14-2.86), 1.87 (1.13-2.12), 2.43 (1.52-3.85), 1.82 (0.92-3.70), and 2.33 (1.01-5.55), respectively.

CONCLUSION

There was an association between long-term opioid use and development of cancer in patients with chronic pain, which should be confirmed in future studies.

Antitumor Anesthetic Strategy in the Perioperatory Period of the Oncological Patient: A Review

The stress response triggered by the surgical aggression and the transient immunosuppression produced by anesthetic agents stimulate the inadvertent dispersion of neoplastic cells and, paradoxically, tumor progression during the perioperative period. Anesthetic agents and techniques, in relation to metastatic development, are investigated for their impact on long-term survival. Scientific evidence indicates that inhaled anesthetics and opioids benefit immunosuppression, cell proliferation, and angiogenesis, providing the ideal microenvironment for tumor progression. The likely benefit of reducing their use, or even replacing them as much as possible with anesthetic techniques that protect patients from the metastatic process, is still being investigated. The possibility of using "immunoprotective" or "antitumor" anesthetic techniques would represent a turning point in clinical practice. Through understanding of pharmacological mechanisms of anesthetics and their effects on tumor cells, new perioperative approaches emerge with the aim of halting and controlling metastatic development. Epidural anesthesia and propofol have been shown to maintain immune activity and reduce catecholaminergic and inflammatory responses, considering the protective techniques against tumor spread. The current data generate hypotheses about the influence of anesthesia on metastatic development, although prospective trials that determinate causality are necessary to make changes in clinical practice.

Opium Use and Cancer Risk: A Comprehensive Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Epidemiological studies have reported inconsistent associations between opium use and cancer risk. We therefore conducted a systematic review and meta-analysis to investigate the relationship between opium use and cancer risk.

METHODS

We searched PubMed, Scopus, ISI Web of Knowledge, and Google Scholar until February 2021 and references of retrieved relevant articles for observational studies that reported the risk of cancer in relation to opium use. Random-effects models were used to calculate pooled effect sizes (ESs) as well as 95% confidence intervals (CIs) for the association between opium use and cancer risk by considering opium doses and types, duration of consumption, and routes of opium use.

RESULTS

In total, 21 observational articles, with a total sample size of 64,412 individuals and 6,658 cases of cancer, were included in this systematic review and meta-analysis. Ever opium users, compared with never opium users, had 3.53 times greater risk of overall cancer (pooled ES: 3.53, 95% CI: 2.60-4.79, P ≤ 0.01). This positive association was also seen for some individual types of cancers except for esophageal and colon cancers. Also, we found that higher opium doses and higher duration of consumption were associated with an increased risk of overall and individual types of cancer. However, the associations between opium doses and the risk of head and neck and larynx cancers were not significant. In terms of the routes of opium use, both opium ingestion and smoking were positively associated with the risk of cancer. Regarding opium types, we found that using teriak, but not shireh, could increase the risk of cancer.

CONCLUSIONS

Our findings showed that opium use, particularly in the form of teriak, is a risk factor for cancer.

Non intubated video-assisted thoracoscopic lung resections (NI-VATS) in COVID times

The emergence of epidemic Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in December 2019 in Wuhan, China causing Coronavirus Disease 2019 (COVID-19) and its rapid expansion around the world, leading to a global pandemic of dimensions not observed at least since the "Spanish influenza" pandemic in 1917-18, has had great consequences at all levels, including social, health and economic spheres. This pandemic situation forces us, as health care workers, to redefine our medical and surgical actions to adapt them to this new reality. It is important, when the rules of the game change, to rethink and to reevaluate if the balance between risk and benefit have moved to a different point of equilibrium, and if our indications of certain surgical interventions need to be redefined. In this article we try to answer the doubts that arise about the suitability of the NI-VATS technique and assess whether its use in these new pandemic circumstances might add advantages, especially in relation to minimize the risks of virus contagion between patients and all healthcare personnel during the surgical procedure, as well as the known advantages described in many articles the last ten years.

Opium Usage and Risk of Head and Neck Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Opium is among the most used substance of abuse worldwide. More than 50 million opium users are there worldwide, majority of whom are in Asia. Opium usage have been reported to be associated with cancer. This study aimed to find the association between opium use or abuse and head and neck cancer.

METHODS

A systematic search was conducted in Medline, Scopus, Cochrane, and Google Scholar database for studies published from inception till 1st November 2019. Two authors independently reviewed the studies, did quality assessment, and extracted data in standardized data extraction form. Pooled estimate of OR for risk of head and neck cancer was calculated using random effects model using the method of DerSimonian and Laird, with the estimate of heterogeneity being taken from the inverse-variance model. Subgroup and sensitivity analysis were performed. The protocol was registered in PROSPERO (CRD42020156049).

RESULTS

Fourteen studies were included in data synthesis (11 case control studies and 3 cohort studies). Eleven case control studies were included in synthesizing the results for meta-analysis. Pooled odds ratio for risk of cancer among opium users for the 11-case control study was 3.85 (2.18-6.79). Heterogeneity was high (I-squared=92.0%, Tau-squared=0.88). There was no publication bias in the study. Subgroup analysis showed highest OR for pooled estimate for risk of laryngeal cancer (19.98 (11.04-36.15)).

CONCLUSION

There was almost four-fold rise in risk of head and neck cancer among opium users compared to non-users.

Mechanisms of Action by Which Local Anesthetics Reduce Cancer Recurrence: A Systematic Review

BACKGROUND

Surgery in concert with anesthesia is a key part of the management of advanced-stage cancers. Anesthetic agents such as opioids and volatile anesthetics have been shown to promote recurrence in preclinical models, whereas some animal models have shown that the use of lidocaine may be beneficial in reducing cancer recurrence. The purpose of this article is to review the current literature to highlight the mechanisms of action by which local anesthetics are thought to reduce cancer recurrence.

METHODS

A systematic review was conducted using the PubMed (1966 to 2018) electronic database. Search terms included "lidocaine," "ropivicaine," "procaine," "bupivicaine," "mepivicaine," "metastasis," "cancer recurrence," "angiogenesis," and "local anesthetics" in various combinations. The search yielded 146 total abstracts for initial review, 20 of which met criteria for inclusion. Theories for lidocaine's effect on cancer recurrence were recorded. All studies were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

RESULTS

Numerous mechanisms were proposed based on the local anesthetic used and the type of cancer. Mechanisms include those that are centered on endothelial growth factor receptor, voltage-gated sodium and calcium channels, transient receptor melanoplastin 7, hyperthermia, cell cycle, and demyelination.

CONCLUSIONS

In vivo models suggest that local anesthetic administration leads to reduced cancer recurrence. The etiology of this effect is likely multifactorial through both inhibition of certain pathways and direct induction of apoptosis, a decrease in tumor migration, and an association with cell cycle-mediated and DNA-mediated effects. Additional research is required to further define the clinical implications.

Untargeted Metabolomics: Biochemical Perturbations in Golestan Cohort Study Opium Users Inform Intervention Strategies

Objective: Over 50 million people worldwide are estimated to use opioids, of which ~30 million use opiates (opium and its derivatives). Use of opiates has been associated with a variety of adverse complications such as neurological and behavioral outcomes, addiction, cancers, diabetes, and cardiovascular disease. While it is well known that opiates exert their neurobiological effects through binding with mu, kappa, and delta receptors to exert analgesic and sedative effects, mechanistic links to other health effects are not well understood. Our study focuses on the identification of biochemical perturbations in Golestan Cohort Study (GCS) opium users.

Methods: We used untargeted metabolomics to evaluate the metabolic profiles of 218 opium users and 80 non-users participating in the GCS. Urine samples were obtained from adult (age 40–75) opium users living in the Golestan Province of Iran. Untargeted analysis of urine was conducted using a UPLC-Q-Exactive HFx Mass Spectrometry and a 700 MHz NMR Spectrometry.

Results: These GCS opium users had a significantly higher intake of tobacco and alcohol and a significantly decreased BMI compared with non-users. Metabolites derived from opium (codeine, morphine, and related glucuronides), nicotine, and curing or combustion of plant material were increased in opium users compared with non-users. Endogenous compounds which differentiated the opium users and non-users largely included vitamins and co-factors, metabolites involved in neurotransmission, Kreb's cycle, purine metabolism, central carbon metabolism, histone modification, and acetylation.

Conclusions: Our study reveals biochemical perturbations in GCS opium users that are important to the development of intervention strategies to mitigate against the development of adverse effects of substance abuse.

Survival features, prognostic factors, and determinants of diagnosis and treatment among Iranian patients with pancreatic cancer, a prospective study

OBJECTIVES

Investigating the survival features, and determinants of treatment and stage at presentation in Iran.

METHODS

461 patients with pancreatic ductal adenocarcinoma (PC) were prospectively enrolled from Shariati hospital, Tehran, Iran, between 2011-2018. All patients underwent endoscopic ultrasonography, computed tomography scanning, and physical examination. Validated questionnaire was completed for the participants and all were actively followed on monthly basis.

RESULTS

Median survival time was 6.5 months, and 1-, and 5-year survival rates were 26.2%, and 1.5%. Patients who were older (p<0.001), illiterate (p = 0.004), unmarried (p = 0.003), rural inhabitant (p = 0.013), opium user (p = 0.039), and had lower body mass index (BMI) (p = 0.002) had lower overall survival. Tumors located in the head of pancreas were more commonly diagnosed at lower stages (p<0.001). Only 10.4% of patients underwent surgery who were more commonly educated (p<0.001), married (p = 0.005), had a tumor located in the head of pancreas (p = 0.016), and were diagnosed at lower stages (p<0.001). After adjustment for potential confounders and risk factors, rural inhabitance (HR: 1.33 (95% CI: 1.01-1.74)), having more symptoms (HR for each increasing symptom: 1.06 (1.02-1.11)), using opium (HR: 1.51 (1.04-2.20)), having a tumor located in the body of pancreas (HR: 1.33 (1.02-1.75)), and having an advanced tumor stage (HR: 2.07 (1.34-3.19)) remained significantly associated with increased risk of mortality. After the adjusting for potential confounders, we did not find significant relationships between smoking, alcohol intake, and BMI with the risk of death among patients with pancreatic cancer.

CONCLUSIONS

Iranian patients with PC have very poor long-term survival. Besides tumor's stage and location, socioeconomic disparities could affect the probabilities of receiving treatment and/or survival in these patients. Opium use is an independent risk factor for mortality among PC patients in Iran.

Intraoperative opioids are associated with improved recurrence-free survival in triple-negative breast cancer

BACKGROUND

Opioid-induced immunomodulation may be of particular importance in triple-negative breast cancer (TNBC) where an immune response is associated with improved outcome and response to immunotherapy. We evaluated the association between intraoperative opioids and oncological outcomes and explored patterns of opioid receptor expression in TNBC.

METHODS

Consecutive patients with stage I-III primary TNBC were identified from a prospectively maintained database. Opioid receptor expression patterns in the tumour microenvironment were analysed using publicly available bulk and single-cell RNA-seq data.

RESULTS

A total of 1143 TNBC cases were retrospectively analysed. In multivariable analysis, higher intraoperative opioid dose was associated with favourable recurrence-free survival, hazard ratio 0.93 (95% confidence interval 0.88-0.99) per 10 oral morphine milligram equivalents increase (P=0.028), but was not significantly associated with overall survival, hazard ratio 0.96 (95% confidence interval 0.89-1.02) per 10 morphine milligram equivalents increase (P=0.2). Bulk RNA-seq analysis of opioid receptors showed that OPRM1 was nearly non-expressed. Compared with normal breast tissue OGFR, OPRK1, and OPRD1 were upregulated, while TLR4 was downregulated. At a single-cell level, OPRM1 and OPRD1 were not detectable; OPRK1 was expressed mainly on tumour cells, whereas OGFR and TLR4 were more highly expressed on immune cells.

CONCLUSIONS

We found a protective effect of intraoperative opioids on recurrence-free survival in TNBC. Opioid receptor expression was consistent with a net protective effect of opioid agonism, with protumour receptors either not expressed or downregulated, and antitumour receptors upregulated. In this era of personalised medicine, efforts to differentiate the effects of opioids across breast cancer subtypes (and ultimately individual patients) should continue.

Effects of Anesthesia on Postoperative Recurrence and Metastasis of Malignant Tumors

It is difficult to control the recurrence and metastasis of malignant tumors; furthermore, anesthesia is considered one of the main influencing factors. There has been increasing clinical attention on the effects of anesthetic drugs and methods on postoperative tumor growth and metastasis. We reviewed the effects of anesthesia on tumor recurrence and metastasis; specifically, the effects of anesthetic agents, anesthesia methods, and related factors during the perioperative period on the tumor growth and metastasis were analyzed. This study can provide reference standards for rational anesthesia formulations and cancer-related pain analgesia protocols for surgical procedures in patients with malignant tumors. Moreover, it contributes toward an experimental basis for the improvement and development of novel anesthetic agents and methods.

Opium use and subsequent incidence of cancer: results from the Golestan Cohort Study

BACKGROUND

Evidence is emerging for a role of opiates in various cancers. In this study, we aimed to investigate the association between regular opium use and cancer incidence.

METHODS

This study was done in a population-based cohort of 50 045 individuals aged 40-75 years from northeast Iran. Data on participant demographics, diet, lifestyle, opium use, and different exposures were collected upon enrolment using validated questionnaires. We used proportional hazards regression models to estimate hazard ratios (HRs) and corresponding 95% CIs for the association between opium use and different cancer types.

FINDINGS

During a median 10 years of follow-up, 1833 participants were diagnosed with cancer. Use of opium was associated with an increased risk of developing all cancers combined (HR 1·40, 95% CI 1·24-1·58), gastrointestinal cancers (1·31, 1·11-1·55), and respiratory cancers (2·28, 1·58-3·30) in a dose-dependent manner (ptrend<0·001). For site-specific cancers, use of opium was associated with an increased risk of developing oesophageal (1·38, 1·06-1·80), gastric (1·36, 1·03-1·79), lung (2·21, 1·44-3·39), bladder (2·86, 1·47-5·55), and laryngeal (2·53, 1·21-5·29) cancers in a dose-dependent manner (ptrend<0·05). Only high-dose opium use was associated with pancreatic cancer (2·66, 1·23-5·74). Ingestion of opium (but not smoking opium) was associated with brain (2·15, 1·00-4·63) and liver (2·46, 1·23-4·95) cancers in a dose-dependent manner (prend<0·01). We observed consistent associations among ever and never tobacco users, men and women, and individuals with lower and higher socioeconomic status.

INTERPRETATION

Opium users have a significantly higher risk of developing cancers in different organs of the respiratory, digestive, and urinary systems and the CNS. The results of this analysis show that regular use of opiates might increase the risk of a range of cancer types.

FUNDING

World Cancer Research Fund International, Cancer Research UK, Tehran University of Medical Sciences, US National Cancer Institute, International Agency for Research on Cancer.

Analgesic and opioid-sparing effects of single-shot preoperative paravertebral block for radical mastectomy with immediate reconstruction: A retrospective study with propensity-adjusted analysis

BACKGROUND

Before radical mastectomy with immediate latissimus dorsi flap reconstruction, single-shot paravertebral block (PVB) can be added to general anesthesia to improve analgesia. As this technique was introduced in 2014 in our centre, our aim was to retrospectively assess its clinical effects.

METHODS

Among 175 patients who underwent surgery over four years (40 receiving PVB), we studied the intra-operatively administered doses of opioids and vasopressors, postoperative pain as estimated by a composite score based on the intensity scores for maximum postoperative pain and the amounts of analgesic drugs, and the report of postoperative nausea/vomiting (PONV). The effect of PVB on these outcomes was tested by propensity-matched comparisons, after a propensity score based on the patient's age, body mass index, ASA and Apfel scores, was calculated. Depending on the outcomes, results are expressed as odds ratios (OR) or regression coefficients (RC), with their 95% confidence interval limits.

RESULTS

PVB reduced the doses of intraoperative opioids (OR for comparisons between the 2nd and 3rd tercile to the 1st tercile, respectively: 0.39 (0.21; 0.67) and 0.10 (0.05; 0.21)). It increased the doses of intraoperative vasopressors (CR = 1.94 (0.89; 2.93). It reduced the composite score for postoperative pain (CR = -0.80 (-1.04; -0.56), and the occurrence of PONV (OR = 0.21 (0.14; 0.37).

CONCLUSIONS

Despite a higher risk of intraoperative hypotension, single-shot PVB seems to markedly improve postoperative analgesia and reduce the amounts of opioids. This could offer many clinical advantages in this type of cancer surgery.

Comparison of Biochemical Recurrence After Robot-assisted Laparoscopic Radical Prostatectomy with Volatile and Total Intravenous Anesthesia

Aims: Recurrence after cancer surgery is a major concern in patients with cancer. Growing evidence from preclinical studies has revealed that various anesthetics can influence the immune system in different ways. The current study compared the long-term biochemical recurrence of prostate cancer after robot-assisted laparoscopic radical prostatectomy (RALP) in terms of selection of anesthetic agent between total intravenous anesthesia (TIVA) with propofol/remifentanil and volatile anesthetics (VA) with sevoflurane or desflurane/remifentanil. Methods: We followed up oncologic outcomes of patients who underwent RALP from two previous prospective randomized controlled trials, and the outcomes of those who received TIVA (n = 64) were compared with those who received VA (n = 64). The follow-up period lasted from November 2010 to March 2019. Results: Both TIVA and VA groups showed identical biochemical recurrence-free survivals at all-time points after RALP. The following predictive factors of prostate cancer recurrence were determined by Cox regression: colloid input [hazard ratio (HR)=1.002, 95% confidence interval (CI): 1.000-1.003; P = 0.011], initial prostate-specific antigen level (HR=1.025, 95% CI: 1.007-1.044; P = 0.006), and pathological tumor stage 3b (HR=4.217, 95% CI:1.207-14.735; P = 0.024), but not the anesthetic agent. Conclusions: Our findings demonstrate that both TIVA with propofol/remifentanil and VA with sevoflurane or desflurane/remifentanil have comparable effects on oncologic outcomes in patients undergoing RALP.

Morpheus and the Underworld-Interventions to Reduce the Risks of Opioid Use After Surgery: ORADEs, Dependence, Cancer Progression, and Anastomotic Leakage

BACKGROUND

Perioperative pain management is a key element of enhanced recovery after surgery (ERAS) programs. A multimodal approach to analgesia as part of a coordinated ERAS includes the reduction of opioid use. This review aims to discuss opioid-related adverse events, strategies to reduce opioid use after surgery, and the relevance to the present "opioid crisis" in North America.

METHODS

A literature review of the pharmacology of opioid drugs, perioperative opioid reduction strategies, and the potential public health benefit was performed. This included current ERAS guidelines on multimodal analgesia, randomized controlled trials on perioperative analgesia, and intervention studies to decrease opioid use, misuse, and diversion in North America.

RESULTS

Reduction of perioperative opioid usage has been endorsed by joint clinical practice guidelines on the management of postoperative pain from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists. Interventions as part of an "opioid bundle" that can be incorporated into ERAS protocols include multimodal analgesia, regional anesthesia, opioid sparing drugs, carbon dioxide humidification during laparoscopy, changing opioid prescription practices, patient and physician education, and proper disposal of unused opioid medications.

CONCLUSION

There are substantial benefits in incorporating opioid reduction strategies into ERAS and clinical practice guidelines. These include faster return of function and mobility, and decreased opioid-related adverse drug events (ORADEs), postoperative morbidity and mortality, and length of hospital stay. Improved oncological outcomes after cancer surgery may be an additional benefit. Evidence-based interventions can also reduce opioid abuse and diversion in the community.

Impact of enhanced recovery on oncological outcomes following minimally invasive surgery for rectal cancer

BACKGROUND

Oncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer.

METHODS

This was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care.

RESULTS

A total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P < 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272).

CONCLUSION

Treatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.

Morphine as a suspect of aiding the propagation of cancer cells

Controlling pain in cancer patients is important for several reasons including patient quality of life (QOL). In moderate-to-severe cancer-pain management, opioid analgesics are indispensable. Among these, morphine is the most representative. Unfortunately, many studies have shown that morphine is potentially associated with cancer growth, recurrence, and metastasis. Specifically, in animal as well as in vivo and in vitro studies, morphine has been demonstrated to have possibly positive effects on cancer progression. However, those effects have not yet been confirmed as entirely harmful, for several reasons: the results of animal and laboratory research have not been subjected to clinical trials; there are as yet no well-designed clinical studies, and indeed, some studies have shown that morphine can have negative, suppression effects on tumor growth. This review paper will present some of the data on the potentially positive relationships between morphine and cancer. It should not be forgotten, though, that such relationships remain controversial, and that pain itself promotes cancer progression.

The Effects of Anesthetics on Recurrence and Metastasis of Cancer, and Clinical Implications

Surgical resection of the primary tumor may enhance the metastasis and recurrence of cancer. The reaction of patients to surgery includes changes of the immune system, the inflammatory system and the neuroendocrine system. In the perioperative period, anesthetics are used both for anesthesia and analgesia. There are several studies showing that the progression of cancer can be influenced by many kinds of anesthetics, although most of these studies are preclinical and thus have not yet influenced clinical recommendations. This review summarizes recent studies regarding the effects of anesthetics on metastasis and recurrence of cancer.

The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis

BACKGROUND

Some studies have suggested using epidural analgesia after cancer surgery to reduce metastasis. This article examines the relationship between regional anesthesia (RA) and cancer metastasis in an array of cancers.

METHODS

We conducted a review of the literature using PubMed and included 67,577 patients across 28 studies in a metaanalysis, evaluating the hazard ratios (HRs) of overall survival, recurrence-free survival, and biochemical recurrence-free survival.

RESULTS

We found no benefit to RA as it relates to cancer. The HR was 0.92 for overall survival, 1.06 for recurrence-free survival, and 1.05 for biochemical recurrence-free survival. Despite the overall analysis showing no benefit, we found some benefit when we evaluated only the randomized trials. However, we found no significant benefit of RA when we evaluated the cancers (gastrointestinal, prostate, breast, and ovarian) individually.

CONCLUSION

This metaanalysis shows that RA has no overall survival, recurrence-free survival, or biochemical recurrence-free survival benefit. However, some individual studies have shown significant benefit in terms of cancer recurrence. Further, RA reduces the use of opioids, which has led to some secondary benefits. Further studies are needed to establish the benefits of RA as it relates to cancer.