Comparing Postoperative Complications and Inflammatory Markers Using Total Intravenous Anesthesia Versus Volatile Gas Anesthesia for Pancreatic Cancer Surgery

Effect of Total Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Microvascular Reconstruction for Head and Neck Cancer: A Randomized Clinical Trial

Importance

Free flap surgery is a lengthy procedure with massive tissue destruction and reconstruction, which makes postoperative pulmonary complications (PPCs) a noticeable issue among patients with head and neck cancer. Propofol-based total intravenous anesthesia (TIVA) has better survival outcomes than inhalational anesthesia (INH) in several types of cancer surgery. A previous retrospective study found that patients in the TIVA group had a lower PPC rate, which may be correlated with a lower intraoperative fluid requirement. We hypothesize that the protective effect remains among patients undergoing free flap surgery for head and neck cancer in a prospective and goal-directed fluid therapy setting.

Objective

To assess the effect of TIVA vs INH on PPCs in patients undergoing microvascular reconstruction for head and neck cancer.

Design, Setting, and Participants

This prospective, 2-arm, randomized clinical trial was conducted at a tertiary hospital in Taiwan; a total of 78 patients 18 years and older with American Society of Anesthesiologists physical status classification 1 to 3 who were scheduled for elective free flap surgery under general anesthesia were included. The trial started in October 2017, completed in October 2019, and finished analysis in January 2022.

Interventions

Patients were enrolled and randomized to the TIVA or INH group. All patients received goal-directed fluid therapy and hemodynamic management if they had a mean arterial pressure (MAP) below 75 mm Hg or a reduction of 10% from baseline MAP.

Main Outcomes and Measures

The primary outcome was a composite of PPCs. The secondary outcomes were the differences in intraoperative hemodynamic values (mean arterial pressure, MAP; cardiac index, CI; systemic vascular resistance index, SVRI; and stroke volume variation, SVV).

Results

A total of 70 patients (65 men [93%]; 5 women [7%]) completed the trial; median (IQR) age was 52.0 (48-59) years in the TIVA group and 57.0 (46-64) years in the INH group. The demographic characteristics were similar between the 2 groups, except that patients in the TIVA group had a slightly lower body mass index. Patients in the TIVA group had a lower risk of developing PPCs (unadjusted odds ratio, 0.25; 95% CI, 0.08-0.80). The TIVA group had significantly higher MAP, lower CI, and higher SVRI than the INH group after the third hour of monitoring. The TIVA group showed a relatively stable hourly MAP, CI, SVRI, and SVV across time points, while the INH group showed a more varying pattern. The generalized estimating equation showed no clinical differences in the trend of hemodynamic parameters across time between groups.

Conclusions and Relevance

In this randomized clinical trial, using propofol-based TIVA reduced the incidence of PPCs in free flap surgery. This finding may be related to more stable hemodynamic manifestations and a lower total balance of fluid throughout the surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03263078.

Anesthetics and Long Term Cancer Outcomes: May Epigenetics Be the Key for Pancreatic Cancer?

Knowledge shows a divergence of results between preclinical and clinical studies regarding anesthesia and postoperative progression of cancer. While laboratory and animal data from then 2000s onwards raised much enthusiasm in this field of research leading to several clinical investigations worldwide, data from randomized trials seem to have killed off hope for many scientists. However several aspects of the actual knowledge should be reevaluated and there is space for new strategies of investigation. In this paper, we perform a critical review of actual knowledge and propose new research strategies with a special focus on anesthetic management and repurposed anesthetic adjuvants for pancreatic cancer.

On the horns of a dilemma: choosing total intravenous anaesthesia or volatile anaesthesia

There are two established techniques of delivering general anaesthesia: propofol-based total intravenous anaesthesia (TIVA) and volatile agent-based inhaled anaesthesia. Both techniques are offered as standard of care and have an established safety track record lasting more than 30 years. However, it is not currently known whether the choice of anaesthetic technique results in a fundamentally different patient experience or affects early, intermediate-term, and longer-term postoperative outcomes. This editorial comments on a recently published study that suggests that inhaled volatile anaesthesia might be associated with fewer postoperative surgical complications than propofol-based TIVA for patients undergoing colorectal cancer surgery. We consider the strengths and limitations of the study, place these findings in the context of the broader evidence, and discuss how the current controversies regarding anaesthetic technique can be resolved, thereby helping to bring precision medicine into the modern practice of perioperative care.

Pancreatic Cancer and Microenvironments: Implications of Anesthesia

Simple Summary

Pancreatic cancer is a lethal malignant neoplasm with less than 10% 5-year relative survival after the initial diagnosis. Several factors may be related to the poor prognosis of pancreatic cancer, including the rapid tumor progression, increased metastatic propensity, insignificant symptoms, shortage of early diagnostic biomarkers, and its tendency toward resistance to both chemotherapy and radiotherapy. Pancreatic neoplastic cells interact intimately with a complicated microenvironment that can foster drug resistance, metastasis, or relapse in pancreatic cancer. In addition, evidence shows that perioperative factors, including surgical manipulation, anesthetics, or analgesics, might alter the tumor microenvironment and cancer progression. This review outlines the up-to-date knowledge of anesthesia implications in the pancreatic microenvironment and provides future anesthetic strategies for improving pancreatic cancer survival.

Abstract

Pancreatic malignancy is a lethal neoplasm, as well as one of the leading causes of cancer-associated mortality, having a 5-year overall survival rate of less than 10%. The average life expectancy of patients with advanced pancreatic cancer does not exceed six months. Although surgical excision is a favorable modality for long-term survival of pancreatic neoplasm, metastasis is initially identified in nearly 80% of the patients by the time of diagnosis, making the development of therapeutic policy for pancreatic cancer extremely daunting. Emerging evidence shows that pancreatic neoplastic cells interact intimately with a complicated microenvironment that can foster drug resistance, metastasis, or relapse in pancreatic cancer. As a result, the necessity of gaining further insight should be focused on the pancreatic microenvironment contributing to cancer progression. Numerous evidence reveals that perioperative factors, including surgical manipulation and anesthetics (e.g., propofol, volatile anesthetics, local anesthetics, epidural anesthesia/analgesia, midazolam), analgesics (e.g., opioids, non-steroidal anti-inflammatory drugs, tramadol), and anesthetic adjuvants (such as ketamine and dexmedetomidine), might alter the tumor microenvironment and cancer progression by affecting perioperative inflammatory or immune responses during cancer surgery. Therefore, the anesthesiologist plays an important role in perioperative management and may affect surgical outcomes. However, the literature on the impact of anesthesia on the pancreatic cancer microenvironment and progression is limited. This review summarizes the current knowledge of the implications of anesthesia in the pancreatic microenvironment and provides future anesthetic strategies for improving pancreatic cancer survival rates.

Anesthesia Options and the Recurrence of Cancer: What We Know so Far?

Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia.

Propofol-based intravenous anesthesia is associated with better survival than desflurane anesthesia in pancreatic cancer surgery

BACKGROUND

Previous researches have shown that anesthetic techniques can influence the patient outcomes of cancer surgery. Here, we studied the relationship between type of anesthetic and patient outcomes following elective, open pancreatic cancer surgery.

METHODS

This was a retrospective cohort study of patients who received elective, open pancreatic cancer surgery between January 2005 and July 2018. Patients were grouped according to the anesthesia they received, namely desflurane or propofol. A Kaplan-Meier analysis was conducted, and survival curves were presented from the date of surgery to death. Univariable and multivariable Cox regression models were used to compare hazard ratios for death after propensity matching. Subgroup analyses were performed for all-cause mortality, cancer-specific mortality, and disease progression.

RESULTS

A total of 68 patients (56 deaths, 82.0%) under desflurane anesthesia, and 72 patients (43 deaths, 60.0%) under propofol anesthesia were included. Fifty-eight patients remained in each group after propensity matching. The propofol anesthesia was associated with improved survival (hazard ratio, 0.65; 95% confidence interval, 0.42-0.99; P = 0.047) in the matched analysis. Subgroup analyses showed significantly better cancer-specific survival (hazard ratio, 0.63; 95% confidence interval, 0.40-0.97; P = 0.037) in the propofol group. Additionally, patients under propofol had less postoperative recurrence, but not fewer postoperative metastases formation, than those under desflurane (hazard ratio, 0.55; 95% confidence interval, 0.34-0.90; P = 0.028) in the matched analysis.

CONCLUSIONS

In a limited sample size, we observed that propofol anesthesia was associated with improved survival in open pancreatic cancer surgery compared with desflurane anesthesia. Further investigations are needed to inspect the influences of propofol anesthesia on patient outcomes of pancreatic cancer surgery.

An ultraviolet-curable, core-shell vaccine formed via phase separation

One of the central challenges in the field of vaccine delivery is to develop a delivery method that maintains antigen stability while also enabling control over the system's release kinetics. Addressing these challenges would not only allow for expanded access to vaccines worldwide but would also help significantly reduce mortality rates in developing countries. In this article, we report the development of single-injection vaccine depots for achieving novel delayed burst release. Synthesized poly(ε-caprolactone) and poly(ε-caprolactone) triacrylate were used to form stationary bubbles within an aqueous solution of 10% carboxymethylcellulose. These polymeric bubbles (referred to as "polybubbles") can then be injected with an aqueous solution of cargo, resulting in the formation of a polymeric shell. The puncture resulting from cargo injection self-heals prior to ultraviolet (UV) curing. UV curing and lyophilization were shown to enhance the stability of the polybubbles. BSA- CF 488 and HIV1 gp120/41 were used as the antigen in the study as a proof-of-concept. Further endeavors to automate the production of polybubbles are underway.