Surgical excision is the mainstay of treatment for potentially curable solid tumours. Metastatic disease is the most important cause of cancer-related death in these patients. The likelihood of tumour metastases depends on the balance between the metastatic potential of the tumour and the anti-metastatic host defences, of which cell-mediated immunity, and natural killer cell function in particular, is a critical component. It is increasingly recognized that anaesthetic technique and other perioperative factors have the potential to effect long-term outcome after cancer surgery. Surgery can inhibit important host defences and promote the development of metastases. Anaesthetic technique and drug choice can interact with the cellular immune system and effect long-term outcome. The potential effect of i.v. anaesthetics, volatile agents, local anaesthetic drugs, opiates, and non-steroidal anti-inflammatory drugs are reviewed here. There is particular interest at present in the effect of regional anaesthesia, which appears to be beneficial. Retrospective analyses have shown an outcome benefit for paravertebral analgesia for breast cancer surgery and epidural analgesia for prostatectomy. Blood transfusion, pain, stress, and hypothermia are other potentially important perioperative factors to consider.

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Summary: The safety and beneficial effect of continuation of propranolol (Pr) through coronary bypass surgery (CBS) was studied in two groups of patients. In the control group (50 patients) Pr was discontinued 24 h before CBS without reinstitution afterwards. In the propranolol group the drug was maintained up to 4 to 10 h before surgery and was restarted within 24 h afterwards. The incidence of subendocardial myocardial infarction was significantly lower in the Pr group (lout of 30 vs 10 out of 50, p < 0.05) while the incidence of transmural infarction was the same in both groups (3 out of 30, 10 %, vs 5 out of 50, 10%). The incidence of supraventricular tachycardias during the first three postoperative days was significantly lower in the propranolol group compared to control (5% vs 30%, P < 0.01). The 24 h urinary epinephrine and norepinephri ne excretion was significantly greater than normal the day before surgery (136 ± 12 vs 39 ± 4,ug/24 h, P < 0.01), and was still high two weeks after surgery (115.1 ± 14 ,ug124 h). There were no complications related to propranolol. The left ventricular function as measured from the systolic time intervals was the same preSupported in part by the Central Ohio Heart Association, Chapter of the American Heart Association. and postoperatively in both groups. The results of this study show that administration of propranolol up to 4 h before coronary bypass and reinstitution immediately afterwards is safe and beneficial.

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