An assessment of the survival impact of multimodal anesthesia/analgesia technique in adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched analysis

Abstract

Background: Studies suggest volatile anesthetics and opioids may enhance the malignant potential of cancer cells. The objective of this single institution retrospective study was to evaluate the survival impact of a multimodal opioid-sparing nonvolatile anesthetic technique (MA) in a group of patients who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for appendiceal carcinomatosis. Methods: Propensity score matching (PSM) and Cox proportional hazard models were used to compare the survivals of patients who received MA (MA group), to those who received volatile-opioid anesthesia (volatile-opioid group). Results: Of the 373 patients, 110 (29%) were in the MA group and 263 (71%) in the volatile-opioid group. The MA group was older (mean ± standard deviation (SD): 55 ± 11 versus 53 ± 10 years, p ¼ .035) and had more patients with ASA scores 3 or 4 (90% versus 81%, p ¼ .032), and those with high grade tumors (18% versus 12%, p ¼ .009). Intraoperative opioid consumption was lower in the MA group (mean morphine equivalents ± SD: 13 ± 10 versus 194 ± 789, p < .0001). After PSM, 107 patients remained in each group. In the adjusted Cox proportional hazards model after PSM, MA was not associated with improved progression free survival (PFS) (HR 1.45, 95% CI [0.94-2.22], p ¼ .093) or overall survival (OS) (HR 1.66, 95% CI [0.86-3.20], p ¼ .128), when compared to volatile-opioid anesthesia. Conclusions: In this retrospective study, a multimodal opioid-sparing nonvolatile anesthetic approach was not associated with improved survival. Precis' statement: In this study of patients undergoing major cancer surgery, the use of multimodal anesthetic and analgesic agents, while avoiding volatile anesthetics and minimizing opioid use was not associated with improved survival. ARTICLE HISTORY

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations — Part I: Preoperative and intraoperative management

“…Preoperative medications include multimodal pain medications and anxiolytics. Only one retrospective study has studied use of multimodal analgesia in 373 patients undergoing CRS with a combination of celecoxib 200e400 mg, pregabalin 75 mg and tramadol 100 mg [76]. These medications in combination with intraoperative non-opioid analgesia like lidocaine infusions, ketamine and dexmedetomidine, reduced postoperative opioid consumption by almost 90% and length of hospital stay by 4e5 days.…”

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

“…[33] The survival benefit of opioid sparing TIVA was only demonstrated in low-volume diseases and lower American Society of Anesthesiologists (ASA) physical status patients. [313234] Use of nitrous oxide during CRS-HIPEC is not evaluated and many researchers and practitioners are using it routinely. Guidelines for anaesthetic management are summarised in Table 3.…”

<p>Anesthesia Options and the Recurrence of Cancer: What We Know so Far?</p>

“…Because of the anti-metastatic effects of TIVA in experimental conditions, there has been a growing interest in translating such beneficial effects into human studies. 6,9,85,125,[128][129][130][131][132][133][134][135][136][137][138][139][140][141][142] The most extensive study was conducted by Wigmore et al, who retrospectively reviewed the impact of propofol-based general anesthesia vs volatile anesthesia in more than 7000 patients. 6 The authors reported a significant benefit in overall survival (HR 95% CI: 1.59, 1.30-1.95) in patients receiving propofol, even after adjusting for metastatic disease.…”