Effects of Thoracic Epidural Anesthesia on Systemic and Local Inflammatory Responses in Patients Undergoing Lung Cancer Surgery: A Randomized Controlled Trial

[Epidural anesthesia in thoracic and abdominal surgery : Current perspectives and practical implications]

With the rise of minimally invasive and robot-assisted surgical techniques, the role of epidural anesthesia (EA) in modern practice necessitates careful re-evaluation. This review explores the relevance of EA in thoracic and abdominal surgery, examining its practical applications, residual indications and considerations for its use. Additionally, alternative pain management strategies, including systemic analgesia, regional nerve blocks and novel perioperative approaches, are assessed for advantages and limitations compared to EA.Traditionally the gold standard for perioperative pain control in thoracic and abdominal procedures, EA provides superior analgesia, reduced pulmonary complications and promotes early postoperative mobilization; however, the shift towards less invasive types of surgery has raised questions about the necessity and risk-benefit profile of EA. Complications such as hypotension, hematoma and rare neurological injuries emphasize the importance of thorough risk assessment.Emerging data show that alternative methods, such as transversus abdominis plane (TAP) blocks, paravertebral blocks and multimodal analgesia provide comparable efficacy in specific patient groups while often demonstrating a better safety profile. Nevertheless, EA remains essential in extensive thoracic surgery, complex abdominal resections and in patients with a high risk for severe postoperative pain or respiratory compromise. Combining EA with enhanced recovery after surgery (ERAS) protocols has also shown promise in improving outcomes.In conclusion, while minimally invasive surgical techniques have transformed perioperative care, EA retains a critical role in selected indications. Individualized planning of anesthesia, weighing EA against evolving alternatives and tailored to surgical and patient-specific factors, is essential. This review highlights the integration of evidence-based strategies to optimize the role of EA in contemporary surgical treatment.

Utilization and Outcomes of Epidural Anesthesia Versus Regional Anesthesia for Thoracic Surgery: An ACS-NSQIP Analysis

OBJECTIVES

To determine the use of epidural anesthesia compared with regional anesthesia as an adjunct to general anesthesia in thoracic surgery over time, and compare length of stay, overall morbidity, serious morbidity, and mortality between epidural and regional anesthesia when utilized as adjuncts to general anesthesia in thoracic surgery.

DESIGN

Retrospective data analysis from the American College of Surgeons National Surgical Quality Improvement Project data registry, years 2014 to 2022.

SETTING

Over 800 U.S. hospitals.

PARTICIPANTS

Patients over 18 years of age undergoing thoracic surgery (N = 18,433).

INTERVENTIONS

Thoracic surgery with general anesthesia and either epidural or regional anesthesia adjuncts.

MEASUREMENTS AND MAIN RESULTS

Peripheral nerve block utilization increased over time, with a steady increase for patients undergoing lobectomy or pneumonectomy. In propensity score-weighted generalized linear models, patients receiving peripheral nerve blocks had shorter hospital stays relative to those receiving epidurals (3.91 days, 95% confidence interval [CI]: 3.83, 3.99 v 5.48 days, 95% CI: 5.40, 5.56, p < 0.001), lower odds of serious morbidity (odds ratio 0.81, 95% CI: 0.76, 0.86, p < 0.001), and lower odds of mortality (odds ratio 0.74, 95% CI: 0.59, 0.92, p = 0.008).

CONCLUSIONS

The rate of peripheral nerve blocks in thoracic surgery increased over time. Patients receiving peripheral nerve blocks, relative to epidural anesthesia, had better outcomes. Future, adequately powered research is needed to evaluate whether findings remain consistent when accounting for other factors (eg, surgical approach, providers, institutions).

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Steroid Premedication Might Protect From Postoperative Erythema Nodosum Leprosum in Leprosy: A Case Report

Leprosy is known for its diverse pathophysiologic involvement and resulting multisystemic manifestation and morbidities. Despite global efforts to eliminate this public health illness, it is still prevalent in some Asian and European countries. Perioperative management of a leprosy patient is challenging owing to the indirect and direct involvement of the airway, respiratory, and cardiac systems; treatment-related side-effects involving the hepato-renal systems affecting the anesthesia techniques and drugs pharmacokinetic and pharmacodynamics. While anaesthesiologists are aware of such happenings and often tailor the anesthesia management for the concerning issues, immunological aspects of the disease and drug-related adverse events are less enquired about, such as type-2 lepra reaction, i.e., erythema nodosum leprosum (ENL), etc. Further, data on perioperative ENL management and prevention are still being determined. We report one case of a 52-year-old female who underwent gynecology surgery and developed ENL on the third postoperative day, which was managed using Steroids. Unfortunately, the patient had a surgical site infection, which required another surgery within the month, while the patient was still under the steroid successfully without any adverse events. Although a single case cannot provide causation or association, the case is presented to highlight the probable preventive action of steroids on the occurrence of postoperative ENL, where surgical stress is considered a risk factor.

The Year in Thoracic Anesthesia: Selected Highlights from 2022

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

Tumor Necrosis Factor Alpha: Implications of Anesthesia on Cancers

Cancer remains a major public health issue and a leading cause of death worldwide. Despite advancements in chemotherapy, radiation therapy, and immunotherapy, surgery is the mainstay of cancer treatment for solid tumors. However, tumor cells are known to disseminate into the vascular and lymphatic systems during surgical manipulation. Additionally, surgery-induced stress responses can produce an immunosuppressive environment that is favorable for cancer relapse. Up to 90% of cancer-related deaths are the result of metastatic disease after surgical resection. Emerging evidence shows that the interactions between tumor cells and the tumor microenvironment (TME) not only play decisive roles in tumor initiation, progression, and metastasis but also have profound effects on therapeutic efficacy. Tumor necrosis factor alpha (TNF-α), a pleiotropic cytokine contributing to both physiological and pathological processes, is one of the main mediators of inflammation-associated carcinogenesis in the TME. Because TNF-α signaling may modulate the course of cancer, it can be therapeutically targeted to ameliorate clinical outcomes. As the incidence of cancer continues to grow, approximately 80% of cancer patients require anesthesia during cancer care for diagnostic, therapeutic, or palliative procedures, and over 60% of cancer patients receive anesthesia for primary surgical resection. Numerous studies have demonstrated that perioperative management, including surgical manipulation, anesthetics/analgesics, and other supportive care, may alter the TME and cancer progression by affecting inflammatory or immune responses during cancer surgery, but the literature about the impact of anesthesia on the TNF-α production and cancer progression is limited. Therefore, this review summarizes the current knowledge of the implications of anesthesia on cancers from the insights of TNF-α release and provides future anesthetic strategies for improving oncological survival.

Impact of pharmacological interventions on intrapulmonary shunt during one-lung ventilation in adult thoracic surgery: a systematic review and component network meta-analysis

BACKGROUND

Intrapulmonary shunt is a major determinant of oxygenation in thoracic surgery under one-lung ventilation. We reviewed the effects of available treatments on shunt, Pao₂/FiO₂ and haemodynamics through systematic review and network meta-analysis.

METHODS

Online databases were searched for RCTs comparing pharmacological interventions and intrapulmonary shunt in thoracic surgery under one-lung ventilation up to March 30, 2022. Random-effects (component) network meta-analysis compared 24 treatments and 19 treatment components. The Confidence in Network Meta-Analysis (CINeMA) framework assessed evidence certainty. The primary outcome was intrapulmonary shunt fraction during one-lung ventilation.

RESULTS

A total of 55 RCTs were eligible for systematic review (2788 participants). The addition of N₂O (mean difference [MD]=-15%; 95% confidence interval [CI], -25 to -5; P=0.003) or almitrine (MD=-13%; 95% CI, -20 to -6; P<0.001) to propofol anaesthesia were efficient at decreasing shunt. Combined epidural anaesthesia (MD=3%; 95% CI, 1-5; P=0.005), sevoflurane (MD=5%; 95% CI, 2-8; P<0.001), isoflurane (MD=6%; 95% CI, 4-9; P<0.001), and desflurane (MD=9%; 95% CI, 4-14; P=0.001) increased shunt vs propofol. Almitrine (MD=147 mm Hg; 95% CI, 58-236; P=0.001), dopexamine (MD=88 mm Hg; 95% CI, 4-171; P=0.039), and iloprost (MD=81 mm Hg; 95% CI, 4-158; P=0.038) improved Pao₂/FiO₂. Certainty of evidence ranged from very low to moderate.

CONCLUSIONS

Adding N₂O or almitrine to propofol anaesthesia reduced intrapulmonary shunt during one-lung ventilation. Halogenated anaesthetics increased shunt in comparison with propofol. The effects of N₂O, iloprost, and dexmedetomidine should be investigated in future research. N₂O results constitute a research hypothesis currently not backed by any direct evidence. The clinical availability of almitrine is limited.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022310313.

Perioperative Inflammatory Response and Cancer Recurrence in Lung Cancer Surgery: A Narrative Review

While surgical resection is the gold standard treatment for solid tumors, cancer recurrence after surgery is common. Immunosurveillance of remnant tumor cells is an important protective mechanism. Therefore, maintenance of anti-tumor cell activity and proper levels of inflammatory mediators is crucial. An increasing body of evidence suggests that surgery itself and perioperative interventions could affect these pathophysiological responses. Various factors, such as the extent of tissue injury, perioperative medications such as anesthetics and analgesics, and perioperative management including transfusions and methods of mechanical ventilation, modulate the inflammatory response in lung cancer surgery. This narrative review summarizes the pathophysiological mechanisms involved in cancer recurrence after surgery and perioperative management related to cancer recurrence after lung cancer surgery.