Epidural Question

[UTSouthwestern]

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Would you put in an epidural on a patient getting a laparotomy for debulking of peritoneal carcinomatosis? My partner has a case upcoming and the patient wants one but he has always been of the "what if there are mets in the blood stream that get introduced to the ED space?"

 

[proman]

Would you put in an epidural on a patient getting a laparotomy for debulking of peritoneal carcinomatosis? My partner has a case upcoming and the patient wants one but he has always been of the "what if there are mets in the blood stream that get introduced to the ED space?"

Yes. Any cancer can be in the bloodstream (think adenocarcinoma and Whipples). Shouldn't be a concern.

 

[cchoukal]

As a resident, I know we did epidurals on gyne-onc patients getting messy debulkings. I have to admit, the complication you describe was never discussed. The literature on regional anesthesia in cancer surgery discusses how, even with clear margins, you never really get all the cancer cells out. Manipulation of the mass probably seeds the circulation, but the idea is that such a small number of cancer cells can be eliminated by the immune system (it is the last point that the pro-regional authors use to explain the benefit of regional in cancer surgery outcomes; regional decreases gas and opiates and their immunosuppresive effects).

 

[urge]

Would you put in an epidural on a patient getting a laparotomy for debulking of peritoneal carcinomatosis? My partner has a case upcoming and the patient wants one but he has always been of the "what if there are mets in the blood stream that get introduced to the ED space?"

So the spinal cord doesn't get perfused EVER?

Your partner is ******ed.

BTW, you can confess it is you.

 

[dhb]

the poor dude is going to die so getting a comfortable post-op is the least you can do.

 

[Noyac]

So the spinal cord doesn't get perfused EVER?

Your partner is ******ed.

BTW, you can confess it is you.

I agree that this is probably the case. I have heard people come up with all types of excuses not to treat people. This is one of the stupidest I have heard. Some are now recommending epidurals in breast cancer pts because it could possibly decrease the recurrence rate during mastectomies. Your partner is just looking for a reason not to do an epidural.

This is as stupid as when I hear people saying they won't place an epidural or a spinal in an HIV pt because it may spread to the CSF and spinal cord. WTF! HIV is in the CNS from the start.

 

[UTSouthwestern]

So the spinal cord doesn't get perfused EVER?

Your partner is ******ed.

BTW, you can confess it is you.

It may end up being me since the patient is adamant about getting one and I would do it for sure and am on call that day.

My partner is conservative, certainly among the best I've ever seen or heard of.

 

[Noyac]

It may end up being me since the patient is adamant about getting one and I would do it for sure and am on call that day.

My partner is conservative, certainly among the best I've ever seen or heard of.

"best" what?

At getting out of work, possibly?

BTW, you guys hiring one of me partners? He's headed back to Dallas but I think he is going with the group that does mostly ortho or whatever. Not the guy we talked about a few years back.

 

[Arch Guillotti]

I wouldn't think twice about doing one.

 

[Frank Rizzo]

yes

 

[proman]

What's the argument against cell saver then?

I think it's the same argument and why surgeons won't use cell saver for oncology. I don't know how valid the argument is (seems like a stretch to me).

Even if it were a valid reason, I don't see the connection with seeding via blood and an epidural.

 

[proman]

It's a good question. I did a quick PubMed search and it appears that you can find viable tumor cells in cell saver blood. Various filters are effective at removing or inactivating them. I don't know what impact the cells would have increasing incidence of mets. I also bet no one is willing to try that study.

 

[UTSouthwestern]

"best" what?

At getting out of work, possibly?

BTW, you guys hiring one of me partners? He's headed back to Dallas but I think he is going with the group that does mostly ortho or whatever. Not the guy we talked about a few years back.

This is one partner that consistently works harder than almost everyone in my group.

No haven't hired anyone from Colorado. If he's headed to here, hope it's to a good group. Several have become predatory.

 

[Planktonmd]

Very interesting and I have to admit I have never thought about it this way.
But I am also not aware of a single case report in the literature where an epidural was thought to have caused CNS Mets.
I guess it would not be difficult to do a retrospective study on this but until then it will remain a personal choice and more speculation than anything else.

 

[geauxg8rs]

put it in. Those cases can be long and painful for all involved(including gas).

 

[proman]

Very interesting and I have to admit I have never thought about it this way.
But I am also not aware of a single case report in the literature where an epidural was thought to have caused CNS Mets.
I guess it would not be difficult to do a retrospective study on this but until then it will remain a personal choice and more speculation than anything else.

N= 1

Anaesth Intensive Care. 2008 Nov;36(6):863-6.
Tumour metastasis at the site of a previous epidural catheter.
Chappell MM, Schoengen HA.

Department of Anaesthetics, Princess Alexandra Hospital, Australia.
Epidural catheters can cause a number of rare, serious complications. The following case report describes a patient who received continuous epidural analgesia following radical cystectomy for bladder cancer Fifty-three days after the cystectomy, the patient underwent emergency surgery for a metastasis at the vertebral level where the epidural catheter had been inserted. A metastasis at the site of an epidural catheter which may be a direct complication of epidural analgesia, is a previously unreported event. Local, anatomical and pathological factors which may have led to the patient developing a metastasis at the epidural site are discussed.

PMID: 19115658 [PubMed - indexed for MEDLINE]

 

[urge]

This is one partner that consistently works harder than almost everyone in my group.

Must be a narcotic abuser. Drug seeking behavior kind of thing...

 

[Pilot Doc]

a previously unreported event.

WHich to me means - very likely safe. Particularly in this patient undergoing a palliative operation who wants one. If it's a particular concern, just have her sign a formal consent noting risk of spinal met.

 

[Planktonmd]

Wow!
One could argue though that the mets at the same level of the epidural insertion could be a simple coincidence.

N= 1

Anaesth Intensive Care. 2008 Nov;36(6):863-6.
Tumour metastasis at the site of a previous epidural catheter.
Chappell MM, Schoengen HA.

Department of Anaesthetics, Princess Alexandra Hospital, Australia.
Epidural catheters can cause a number of rare, serious complications. The following case report describes a patient who received continuous epidural analgesia following radical cystectomy for bladder cancer Fifty-three days after the cystectomy, the patient underwent emergency surgery for a metastasis at the vertebral level where the epidural catheter had been inserted. A metastasis at the site of an epidural catheter which may be a direct complication of epidural analgesia, is a previously unreported event. Local, anatomical and pathological factors which may have led to the patient developing a metastasis at the epidural site are discussed.

PMID: 19115658 [PubMed - indexed for MEDLINE]

 

[Pilot Doc]

Wow!
One could argue though that the mets at the same level of the epidural insertion could be a simple coincidence.

That would be my bet. But even assuming it was real, if this has never seen the literature before 2008, makes me think the risk has to be quite low.

 

[proman]

Can anyone get the full-text of that article? I bet they had a preop CT scan.

 

[Noyac]

This is one partner that consistently works harder than almost everyone in my group.

No haven't hired anyone from Colorado. If he's headed to here, hope it's to a good group. Several have become predatory.

I will try to get the group name. I like this guy and would hate to see him make a bad decision.👍

 

[spam]

This is one partner that consistently works harder than almost everyone in my group.

No haven't hired anyone from Colorado. If he's headed to here, hope it's to a good group. Several have become predatory.

Which are predatory? Private message me if you don't want to post it on the board?

Thx.