Effects of epidural anesthesia and postoperative epidural analgesia on immune function in esophageal carcinoma patients undergoing thoracic surgery

Analysis of factors related to anesthetic management affecting acute kidney injury occurring within 72 h after esophagectomy for esophageal cancer: a historical cohort study

BACKGROUND

The effects of factors related to anesthetic management, including anesthesia methods and infusion volume, on acute kidney injury (AKI) after esophagectomy have not been thoroughly investigated.

METHODS

A historical cohort study of patients who underwent esophagectomy between January 2008 and December 2022 was conducted. AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria within 72 h after esophagectomy. Logistic regression was used to model the association between perioperative factors, including factors related to anesthetic management, and postoperative AKI.

RESULTS

Of 1005 patients, 48 patients (4.8%) had AKI (40 stage 1 and 8 stage 2). AKI patients were older (67.8 vs. 65.0 years, P = 0.046) and more likely to have hypertension (72.9 vs. 37.9%, P < 0.001), chronic kidney disease (39.6 vs. 14.3%, P < 0.0001), red blood cell (RBC) transfusions (12.5 vs. 3.4%, P = 0.0085), and longer duration of anesthesia (518 vs. 490 min, P = 0.0058) than non-AKI patients. AKI patients were less likely to have epidural anesthesia (72.9 vs. 91.5%, P < 0.001). The distribution of inhaled anesthetics chosen was not significantly different between AKI and non-AKI patients. On multivariable logistic regression analysis, AKI was associated with the Brinkman index (per 100 units, odds ratio (OR) = 1.06), hypertension (OR = 3.39), chronic kidney disease (OR = 2.58), duration of anesthesia (per 10 min, OR = 1.03), epidural anesthesia (OR = 0.35) and RBC transfusion (OR = 3.27).

CONCLUSIONS

Except for epidural anesthesia, no significant association was found between AKI and factors related to anesthetic management. Epidural anesthesia may protect against early postoperative AKI in patients undergoing esophagectomy.

Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer

Background

Enhanced Recovery After Surgery (ERAS) protocol for esophagectomy may reduce the high incidence of postoperative morbidity and mortality. The aim of this study was to assess the impact of properly conducted ERAS protocol with specific emphasis on fluid balance and opioid-sparing anesthesia (OSA) on postoperative major morbidity and mortality after esophagectomy.

Methods

Patients undergoing elective esophagectomy for esophageal cancer at the Hospital for Digestive Surgery, University Clinical Center of Serbia, from December 2017 to March 2021, were included in this retrospective observational study. Patients were divided into two groups: the ERAS group (OSA, intraoperative goal-directed therapy, and postoperative “near-zero” fluid balance) and the control group (opioid-based anesthesia, maintenance mean blood pressure ≥ 65 mmHg, and liberal postoperative fluid management). The primary outcome was major morbidity within 30 days from surgery and 30-day and 90-day mortality. Multivariable analysis was used to examine the effect of the ERAS protocol.

Results

A total of 121 patients were divided into the ERAS group (69 patients) and the control group (52 patients). Patients in the ERAS group was received less fentanyl, median 300 (interquartile range (IQR), 200–1,550) mcg than in control group, median 1,100 (IQR, 650–1750) mcg, p &lt; 0.001. Median intraoperative total infusion was lower in the ERAS group, 2000 (IQR, 1000–3,750) mL compared to control group, 3,500 (IQR, 2000–5,500) mL, p &lt; 0.001. However, intraoperative norepinephrine infusion was more administered in the ERAS group (52.2% vs. 7.7%, p &lt; 0.001). On postoperative day 1, median cumulative fluid balance was 2,215 (IQR, −150-5880) mL in the ERAS group vs. 4692.5 (IQR, 1770–10,060) mL in the control group, p = 0.002. After the implementation of the ERAS protocol, major morbidity was less frequent in the ERAS group than in the control group (18.8% vs. 75%, p &lt; 0.001). There was no statistical significant difference in 30-day and 90-day mortality (p = 0.07 and p = 0.119, respectively). The probability of postoperative major morbidity and interstitial pulmonary edema were higher in control group (OR 5.637; CI95%:1.178–10.98; p = 0.030 and OR 5.955; CI95% 1.702–9.084; p &lt; 0.001, respectively).

Conclusion

A major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.

Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines

BACKGROUND

Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team.

MATERIAL AND METHODS

An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript.

CONCLUSION

Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.

Systemic inflammatory changes and their clinical implications following thoracic cancer surgery

Trauma that follows every surgical procedure triggers an inflammatory response, which in the majority of the cases reflects the associated tissue damage. Tissue regeneration, postoperative outcomes, and systemic antibacterial activity are highly dependent on the initial inflammatory response elicited by surgical trauma. More specifically, in thoracic surgery, systemic cytokine and cellular changes have an impact on several measured postoperative outcomes. Lastly, the introduction of video-assisted and robotic-assisted thoracic surgery has been shown to provide improved postoperative outcomes with altered systemic inflammatory response, when compared to open thoracic surgery. This review outlines the major systemic inflammatory changes observed in thoracic cancer surgery as well as its clinical significance.

Evaluation of the addition of bupivacaine to intrathecal morphine for intraoperative and postoperative pain management in open liver resections

BACKGROUND

Intrathecal morphine is a popular and effective regional technique for pain control after open liver resection, but its delayed analgesic onset makes it less useful for the intraoperative period. The aim of this retrospective study was to compare the analgesic efficacy and other secondary benefits of the addition of hyperbaric bupivacaine to intrathecal morphine ± fentanyl. We hypothesized that bupivacaine could serve as an analgesic "bridge" prior to the onset of intrathecal morphine/fentanyl thereby lowering opioid consumption and enhancing recovery.

METHODS

Cumulative intraoperative and postoperative opioid consumption as well as other intra- and postoperative variables were collected and compared between groups receiving intrathecal morphine alone or intrathecal morphine ± hyperbaric bupivacaine.

RESULTS

Sixty-eight patients were selected for inclusion. Cumulative intraoperative morphine consumption was significantly reduced in the bupivacaine group while other intraoperative parameters such as intravenous fluids, blood loss, and vasopressors did not differ. There was a statistically significant improvement in time to first bowel movement in the experimental group.

DISCUSSION

The intraoperative opioid sparing effects and improved time to bowel function with the addition of hyperbaric bupivacaine to intrathecal morphine may make this technique an easy and low risk method of enhancing recovery after open liver resection.

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Simple Summary

Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues.

Abstract

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Anesthesia technique and serum cytokine concentrations in the elective cesarean section

Background:

Anesthesiologists should obtain the best technique for cesarean section (CS). This study designed to compare the effect of general anesthesia (GA) and spinal anesthesia (SA) on immune system function in elective CS.

Materials and Methods:

This descriptive study was performed on forty candidates for elective CS. They were randomly divided into GA and SA groups. The serum concentrations of interleukin (IL)-4, IL-6, IL-10, and IL-17 and interferon-gamma (IFN-γ) were measured using ELISA method prior to anesthesia (T0), immediately after the uterine incision (T1), 2 h post CS (T2), and 24 h post CS (T3). Data were analyzed using descriptive statistics and Chi-square, independent t-test, and repeated measures.

Results:

No significant differences were observed between the GA and SA groups regarding the serum levels of IL-4, IL-6, IL-10, IL-17, and IFN-γ. The serum levels of transforming growth factor beta (TGF-β) in the SA group were significantly (P = 0.003) more than that of the GA group at T3.

Conclusion:

According to the angiogenesis properties of TGF-β, it seems that SA probably affects the rate of recovery more than that of the GA.

Application of dexmedetomidine-assisted intravertebral anesthesia in hip replacement and its influence on T-lymphocyte subsets

Application of dexmedetomidine-assisted intravertebral anesthesia for elderly patients with hip replacement and its influences on T-lymphocyte subsets in peripheral blood were assessed. Eighty-six patients undergoing intravertebral anesthesia in hip replacement were treated as group A, and one hundred patients undergoing intravertebral anesthesia combined with dexmedetomidine were treated as group B. Hemodynamic changes in both groups were compared 5 min before anesthesia (T0), immediately after skin incision (T1) and after surgery (T2). General operation conditions of patients in both groups were recorded. T-lymphocyte subsets, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), visual analogue scale (VAS) pain scores and mini-mental state examination (MMSE) cognitive function changes before surgery and 24 h after surgery were compared between the groups, and the incidence of complications in both groups after 24 h was recorded. The recovery time of patients in group B was shorter than that of group A (P<0.05). Changes of systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate fluctuations in group B were lower than those in group A (P<0.05). At 24 h after surgery, VAS scores of group B were lower than those of group A (P<0.05); levels of IL-6 and TNF-α were lower than those of group A (P<0.05); CD3⁺ cells, CD4⁺ cells, CD8⁺ cells, and CD4/CD8 ratio were higher than those of group A (P<0.05), and MMSE score was higher than that of group A (P<0.05). The incidence of gastrointestinal reactions and postoperative cognitive dysfunction (POCD) in group B was lower than that in group A (P<0.05). In conclusion, administration of dexmedetomidine can effectively shorten the recovery time of patients, stabilize intraoperative hemodynamics of patients, protect immune function, and reduce postoperative pain and POCD occurrence during anesthesia of hip replacement.

The effect of anesthesia on the postoperative systemic inflammatory response in patients undergoing surgery: A systematic review and meta-analysis

BACKGROUND

Surgical injury stimulates the systemic inflammatory response. The magnitude of the postoperative systemic inflammatory response has been shown to be significantly associated with short and long-term outcomes following surgery of varying severity. Different anesthetic techniques for surgery may have an impact on the postoperative systemic inflammatory response and on the rate of the postoperative infective complications.The aim of the present systematic review was to examine the relationship between perioperative anesthesia, the postoperative systemic inflammatory response and postoperative infective complications in patients undergoing surgery.

METHODS

This was carried out using PubMed and other established databases from 1987 up to March 2018. In particular, randomized controlled studies and systemic inflammation markers, interleukin 6 and C-reactive protein were examined.

RESULTS

Overall, 60 controlled, randomized clinical trials were included in the review. The mean or median values of both interleukin 6 and C-reactive protein were taken for each study and the mean value was calculated for each anesthetic group at sampling points of 12-24 and 24-72 hours for interleukin 6 and C-reactive protein respectively. When taking the magnitude of surgery into account, TIVA using propofol was significantly associated with a reduction in particular C-reactive protein (P = .04). However, there were no other specific anesthetic methods including general, regional and combined anesthetics that were associated with a reduction in either interleukin 6 or C-reactive protein.

CONCLUSION

There is some evidence that anesthetic regimens may reduce the magnitude of the postoperative systemic inflammatory response. However, the studies were heterogeneous and generally of low quality.Future, well conducted, adequately powered studies are required to clarify the effect of anesthesia on the postoperative systemic inflammatory response and infective complications.

Biomarkers for Evaluating the Inflammation Status in Patients with Cancer

Inflammation can be a causative factor for carcinogenesis or can result from a consequence of cancer progression. Moreover, cancer therapeutic interventions can also induce an inflammatory response. Various inflammatory parameters are used to assess the inflammatory status during cancer treatment. It is important to select the most optimal biomarker among these parameters. Additionally, suitable biomarkers must be examined if there are no known parameters. We briefly reviewed the published literature for the use of inflammatory parameters in the treatment of patients with cancer. Most studies on inflammation evaluated the correlation between host characteristics, effect of interventions, and clinical outcomes. Additionally, the levels of C-reactive protein, albumin, lymphocytes, and platelets were the most commonly used laboratory parameters, either independently or in combination with other laboratory parameters and clinical characteristics. Furthermore, the immune parameters are classically examined using flow cytometry, immunohistochemical staining, and enzyme-linked immunosorbent assay techniques. However, gene expression profiling can aid in assessing the overall peri-interventional immune status. The checklists of guidelines, such as STAndards for Reporting of Diagnostic accuracy and REporting recommendations for tumor MARKer prognostic studies should be considered when designing studies to investigate the inflammatory parameters. Finally, the data should be interpreted after adjusting for clinically important variables, such as age and cancer stage.

Enhanced recovery after surgery in liver resection: current concepts and controversies

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: A single-center, randomized controlled trial

BACKGROUND

Appropriate postoperative pain management can improve outcomes in patients with esophageal cancer (EC).

OBJECTIVE

To compare different combinations of anesthesia and analgesia techniques in patients with EC undergoing open thoracotomy.

METHODS

This randomized, controlled, open-label trial enrolled 100 patients with EC (aged 40-65 years; American Society of Anesthesiologists [ASA] grade I/II) receiving elective surgery at Jiangsu Province Hospital (China) between July 2016 and December 2017. Patients were randomized to 4 groups (n = 25 per group): total intravenous general anesthesia plus patient-controlled intravenous analgesia (TIVA/PCIA); TIVA plus patient-controlled epidural analgesia (TIVA/PCEA); thoracic epidural anesthesia with intravenous general anesthesia plus PCIA (TEA-IVA/PCIA); and TEA-IVA/PCEA (TEA-IVA plus PCEA). Primary outcomes were plasma cortisol level (measured at baseline, 2 h after skin incision, surgery completion, and 24 and 48 h post-surgery) and pain (assessed at 24, 48, and 72 hours post-surgery using a visual analog scale). Secondary outcomes included time to first flatus, hospital stay and treatment costs. Postoperative adverse events (AEs) were analyzed.

RESULTS

Baseline and operative characteristics were similar between the 4 groups. Plasma cortisol level increased (P <.05 vs baseline) earlier in the TIVA groups (2 h after skin incision) than in the TEA-IVA groups (24 h after surgery). At 48 hours after surgery, plasma cortisol had returned to baseline levels in the PCEA groups but not in the PCIA groups. VAS pain scores at rest and during coughing were lower in the PCEA groups than in the PCIA groups (P <.05). Compared with the PCIA groups, the PCEA groups had shorter time to first flatus and shorter hospital stay, while use of TEA-IVA lowered the costs of intraoperative anesthesia (P <.05). However, the PCEA groups had a higher incidence of nausea, vomiting, and pruritus.

CONCLUSION

Thoracic epidural anesthesia/analgesia can reduce the stress response, improve postoperative recovery and reduce hospital stay and costs for patients with EC.

Long-Term Oncologic Outcomes for Patients Undergoing Volatile Versus Intravenous Anesthesia for Non-Small Cell Lung Cancer Surgery: A Retrospective Propensity Matching Analysis

Propofol-based total intravenous anesthesia (TIVA) has been reported to improve long-term outcome following cancer surgery, when compared with inhalation agents. However, such investigational reports are still controversial, and no studies have been conducted in relation to non-small cell lung cancer (NSCLC) surgery. The present study aimed to compare the favorable effects of TIVA versus inhalation agents on recurrence-free survival and overall survival after curative resection of NSCLC. This retrospective cohort study examined medical records of the patients who were diagnosed with NSCLC and underwent curative resection at Seoul National University Bundang Hospital from August 2003 to July 2012. The primary outcome included the comparison of postoperative overall survival and recurrence-free survival in both groups. To balance the 2 groups for analysis, a propensity matching method was used, and stratified Cox proportional hazard models were used for statistical analysis. This study included 943 cases of NSCLC for final analysis, and the cases were divided into the TIVA group (n = 749) and inhalation group (n = 194). Propensity matching produced 196 patients in each group. The final analysis revealed no significant difference in the hazard ratio (HR) for recurrence between the TIVA and inhalation groups ( P = .233). The HR for death between the 2 groups was not significantly different either ( P = .551). In this study, we found no benefit of propofol-based TIVA for long-term oncologic outcome after NSCLC surgery, relative to inhalation agents.

The cortisol stress response induced by surgery: A systematic review and meta-analysis

OBJECTIVE

Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined.

DESIGN

We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters.

METHODS

We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta-analysis and plotted over time.

RESULTS

We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas more invasive surgeries caused a cortisol surge that was more pronounced in older subjects, women and patients undergoing open surgery and general anaesthesia. The duration of the procedure and the use of etomidate for induction of anaesthesia did not affect the cortisol response.

CONCLUSIONS

The peri-operative cortisol stress response is dynamic and influenced by patient-specific, surgical and anaesthetic features. However, the available evidence is derived from highly heterogeneous studies, with only two of 71 studies measuring cortisol by mass spectrometry, which currently prevents a precise and reproducible definition of this response.

Postoperative Regional Analgesia Is Effective in Preserving Perforin-Expressing Lymphocytes in Patients After Total Knee Replacement

BACKGROUND Pain and surgical stress cause a pro-inflammatory response followed by downregulation of the immune response, which can increase the incidence of postoperative complications, such as infections or prolonged wound healing. T lymphocytes and natural killer (NK) cells have cytotoxic potential and are crucial components of cellular immunity, which is important for maintenance of immune balance. The aim of this study was to analyze the effects of 3 types of postoperative analgesia on the preservation and cytotoxic potential of T lymphocytes, NK cells, and their subpopulations, as well as NKT cells, in patients after total knee replacement (TKR) to find the most effective analgesic technique for mitigating immune suppression. MATERIAL AND METHODS Forty-eight patients scheduled for TKR were randomly allocated to Group 1 (patients received epidural analgesia), Group 2 (patients received sciatic and femoral nerve block), or Group 3 (patients received multimodal systemic analgesia). Pain intensity was assessed at rest and on movement before, immediately after, and at 24 and 72 h after surgery. Blood samples were collected at the same time points and peripheral blood mononuclear cells were isolated. The frequencies of T lymphocytes, NK cells, and NKT cells, as well as their perforin expression, were simultaneously detected and analyzed by flow cytometry. RESULTS Patients in Group 1 and Group 2 experienced less severe pain than those in Group 3. The frequencies and perforin levels of T lymphocytes, their subsets, and NKT cells were significantly lower in Group 3 than in Group 1 and Group 2. CONCLUSIONS The present study confirmed that regional analgesia is more effective in maintaining cell-mediated immunity and perforin expression in peripheral blood lymphocytes in patients after TKR.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Perioperative events influence cancer recurrence risk after surgery

Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer.

Effects of oxycodone on immune function in patients undergoing radical resection of rectal cancer under general anesthesia

This study aims to explore the effect of oxycodone hydrochloride injection on the immune function of patients who underwent radical resection of rectal cancer under general anesthesia.Eighty patients were enrolled and randomly divided into group A and B (n = 40, each). All patients underwent general intravenous anesthesia. At the end of surgery, each patient in group A was injected with 5 mg (5 mL) of oxycodone hydrochloride, while 5 mg (5 mL) of morphine hydrochloride in group B. Venous blood was withdrawn in both groups at different time points. Changes in the numbers of T lymphocyte subsets and natural killer (NK) cells were determined by flow cytometry.First the numbers of T lymphocyte subsets and NK cells at T1, T2, T3, and T4 decreased in both groups, compared with those at T0, and the differences were statistically significant. Furthermore, the numbers reduced to a minimum at T2 and began to recover at T3. Second the differences between group A and B at T1, T2, T3, and T4 were statistically significant; and the numbers of T lymphocytes and NK cells were higher in group A than in group B at corresponding time points.Oxycodone hydrochloride and morphine hydrochloride both have inhibitory effects on immune function in patients undergoing radical resection of rectal cancer after surgery. However, oxycodone hydrochloride has a smaller effect compared to morphine hydrochloride.

Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial

BACKGROUND

Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol.

METHODS

Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates.

RESULTS

There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints.

CONCLUSIONS

There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.