lower abdominal surgery

[nap$ter]

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ie low anterior resections, RRP's, gyn etc

do you guys routinely place epidurals for these patients?

doing my first rectal-ectomy as an attending tomorrow (opiate naive, otherwise well pt), and on the fence about placing an epidural or not...

 

[Arch Guillotti]

ie low anterior resections, RRP's, gyn etc

do you guys routinely place epidurals for these patients?

doing my first rectal-ectomy as an attending tomorrow (opiate naive, otherwise well pt), and on the fence about placing an epidural or not...

no, not routinely

 

[sevoflurane]

TAP 'em.

 

[B-Bone]

ie low anterior resections, RRP's, gyn etc

do you guys routinely place epidurals for these patients?

doing my first rectal-ectomy as an attending tomorrow (opiate naive, otherwise well pt), and on the fence about placing an epidural or not...

we do for almost all big gyn procedures and colorectal cases as well as some RRP's. All of this is at the request of the surgeons. Necessary? Absolutely not. Where I trained, we never did any of this. But patients are happier, surgeons get fewer pain calls at night, and everybody takes the perspective that the anesthesiologists are providing a valuable service. This leads to respect from our surgical colleagues, nursing staff and the patients.

 

[Pooh & Annie]

we do for almost all big gyn procedures and colorectal cases as well as some RRP's. All of this is at the request of the surgeons. Necessary? Absolutely not. Where I trained, we never did any of this. But patients are happier, surgeons get fewer pain calls at night, and everybody takes the perspective that the anesthesiologists are providing a valuable service. This leads to respect from our surgical colleagues, nursing staff and the patients.

The surgery service still handles pain calls first when the patient has an epidural?

 

[epidural man]

ie low anterior resections, RRP's, gyn etc

do you guys routinely place epidurals for these patients?

doing my first rectal-ectomy as an attending tomorrow (opiate naive, otherwise well pt), and on the fence about placing an epidural or not...

4 large retrospective trials showing that regional technique helps decrease the reoccurrence of cancer after surgery for resection of the tumor - so if the surgery is for a tumor, I would HIGHLY recommend it.

Or....do a lidocaine infusion.

 

[periopdoc]

No. Not unless the surgery is above the umbilicus.

- pod

 

[PMPMD]

4 large retrospective trials showing that regional technique helps decrease the reoccurrence of cancer after surgery for resection of the tumor - so if the surgery is for a tumor, I would HIGHLY recommend it.

Or....do a lidocaine infusion.

I found 2 that showed no benefit. The survival benefit of epidurals may depend on tumor type or patient factors.

 

[PMPMD]

BMJ 2011; 3421491 doi: 10.1136/bmj.d1491 (Published 29 March 2011)

Research
Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial
OPEN ACCESS
Paul S Myles, professor1, director2, Philip Peyton, consultant3, Brendan Silbert, consultant4, Jennifer Hunt, research coordinator1, John R A Rigg, retired consultant5, Daniel I Sessler, professor and chair6 for the ANZCA Trials Group Investigators
+ Author Affiliations

1Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
2Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne
3Department of Anaesthesia, Austin Hospital, Heidelberg, Australia
4Department of Anaesthesia, St Vincent’s Hospital, Fitzroy, Australia
5Australian and New Zealand College of Anaesthetists Trials Group, Melbourne
6Department of Outcomes Research, Cleveland Clinic, Cleveland, USA
Correspondence to: P S Myles [email protected]
Accepted 31 January 2011
Abstract
Objective To compare long term recurrence of cancer and survival of patients having major abdominal surgery for cancer.

Design Long term follow-up of prospective randomised controlled clinical trial in which patients were randomly assigned to receive general anaesthesia with or without epidural block for at least three postoperative days.

Setting 23 hospitals in Australia, New Zealand, and Asia.


Participants 503 adult patients who had potentially curative surgery for cancer.

Main outcome measure Cancer-free survival (analysis was by intention to treat).

Results Long term follow-up data were available for 94% (n=446) of eligible participants. The median time to recurrence of cancer or death was 2.8 (95% confidence interval 0.7 to 8.7) years in the control group and 2.6 (0.7 to 8.7) years in the epidural group (P=0.61). Recurrence-free survival was similar in both epidural and control groups (hazard ratio 0.95, 95% confidence interval 0.76 to 1.17; P=0.61).

Conclusion Use of epidural block in abdominal surgery for cancer is not associated with improved cancer-free survival.

 

[PMPMD]

Association between epidural analgesia and cancer recurrence after colorectal cancer surgery.

AuthorsGottschalk A, et al. Show all Journal
Anesthesiology. 2010 Jul;113(1):27-34.

Affiliation
Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia 22908, USA.

Comment in
Anesthesiology. 2011 Mar;114(3):717-8; author reply 718.
Anesthesiology. 2011 Mar;114(3):717; author reply 718.
Abstract
INTRODUCTION: Animal studies suggest that regional anesthesia and optimal postoperative analgesia independently reduce cancer metastasis. Retrospective clinical studies suggest reductions in recurrence of several cancer types in patients receiving perioperative neuraxial analgesia. Thus, the authors determined the association between perioperative epidural analgesia and cancer recurrence in patients undergoing colorectal cancer surgery.

METHODS: After obtaining approval of institutional review board, the authors reviewed the records of 669 patients undergoing colorectal cancer surgery between January 2000 and March 2007. Follow-up ended in November 2008. The authors' primary outcome was time to cancer recurrence. Cox proportional hazards models were used.

RESULTS: Two hundred fifty-six patients who received epidural analgesia and 253 who did not were analyzed in a multivariable model to assess the association between epidural use and cancer recurrence. Overall, no association between epidural use and recurrence was found (P = 0.43), with an adjusted estimated hazard ratio of 0.82 (95% CI 0.49-1.35). In post hoc analyses, epidural use was associated with a lower cancer recurrence in older patients (age older than 64 yr), but not in younger (interaction P = 0.01). A sensitivity analysis using propensity score analysis found similar results.

CONCLUSION: In contrast to previous retrospective studies in the colon, breast, and prostate cancer surgery, the authors found that the use of epidural analgesia for perioperative pain control during colorectal cancer surgery was not associated with a decreased cancer recurrence; however, a potential benefit was observed in older patients. The benefit of regional anesthesia on cancer recurrence may thus depend on the specific tumor type.

PMID 20508494 [PubMed - indexed for MEDLINE]

 

[Jeff05]

4 large retrospective trials showing that regional technique helps decrease the reoccurrence of cancer after surgery for resection of the tumor - so if the surgery is for a tumor, I would HIGHLY recommend it.

Or....do a lidocaine infusion.

the study comparing epidurals to IV lido is flawed beyond belief. can't believe it was actually allowed to be published in a peer-reviewed journal.

 

[ssmallz]

4 large retrospective trials showing that regional technique helps decrease the reoccurrence of cancer after surgery for resection of the tumor - so if the surgery is for a tumor, I would HIGHLY recommend it.

Or....do a lidocaine infusion.

Before we start changing our practice we should try to figure out why these results are occurring. I would be very reluctant to believe that epidurals for post op pain control can prevent recurrence of CA because I can't figure out a plausible mechanism where one influences the other. Until there is significant evidence for this practice and it's becoming a mainstream idea I would downplay this benefit and evaluate an epidural based strictly on a pain control basis. Just remember there are lies, damn lies, and statistics

 

[proman]

The mechanisms that I've heard proposed all revolve around immune suppression. WBCs have opioid receptors that inhibit their activity. By minimizing IV opioids, epidurals could theoretically have less innate immunosuppression. Same thing with attenuating the inflammatory response of surgery. Does it really make a difference? I really doubt it, and there would have to be a well done prospective study to really justify epidurals for this purpose.

 

[epidural man]

Before we start changing our practice we should try to figure out why these results are occurring. I would be very reluctant to believe that epidurals for post op pain control can prevent recurrence of CA because I can't figure out a plausible mechanism where one influences the other. Until there is significant evidence for this practice and it's becoming a mainstream idea I would downplay this benefit and evaluate an epidural based strictly on a pain control basis. Just remember there are lies, damn lies, and statistics

Oh there is no question why it (possibly) decreases the risk of reoccurance of cancer. And it probably has little to do with post-op pain. In fact, the most recent retrospective analysis shows that epidurals placed after surgery for pain control (for ovarian cancer) showed no difference, but the ones placed before surgery and was used during surgery did.

And agree, statistics lie. And also, all the clinical data is from retrospective analysis - the worst form of evidence.

However, the reason it probably works is that it decreases the use of peri-operative opioid use, and decrease the amount of gas used. Both have been shown as potent immune function inhibitors.

The perioperative period during resection of cancer is probably MUCH more important than what has ever been considered. It is during this time that cancer cells are seeded in the blood, and it is during that time that our immune system (and more specifically) our NK cells are functioning overtime.

Here are editorials on the subject. View attachment discussion of cancer and anesthetic technique.pdfView attachment Perioperative Period in Recurrence of CA.pdf


Yeager has been looking at the immune function and opioids for a long time. He has found that opioids are potent inhibitors of much of the specific cells of the immune tree. Here is just one of the many articles he has written on the subject.

Here is an article I found absolutely fascinating. It discusses some of the proteins that cancers need to survice and seed and all that stuff, and shows how if you decrease opioid use (or use regional) you are able to maintain normal levels of NK and other immune function cells, and thus decrease the markers that presumably help cancers seed in distant locations.

And that isn't even the whole story. What is really amazing is that some tumors actually have mu receptors on them - and mu agonists make tumor cells proliferate and metastisize. Look at this crazy article. They did alot of cool stuff that I won't describe here, but it demonstrates some compeling evidence towards this whole idea.

It has been long known that patients with pancreatic cancer that get celiac plexus blocks live longer. It's probably because they use less opioids.

So, there is laboratory data and people and animal data that show that opioids (and gas) decrease immune function. There is data that shows that regional decrease tumor cell markers perio-operatively. There is way cool data that show that knock-out mice (no mu receptors) that get the tumor don't get metastatic lesions (and a bunch of other cool stuff in that article - ya got to read it). And finally, there is retrospective data that also indicates all this other stuff people have been writing about for years. I think it is fine if you don't want to change your practice. You can wait for the prospective data in 10 years. In my mind, there is little downside to using regional since I probably would have advocated for it without all that data.

 

[nap$ter]

Oh there is no question why it (possibly) decreases the risk of reoccurance of cancer. And it probably has little to do with post-op pain. In fact, the most recent retrospective analysis shows that epidurals placed after surgery for pain control (for ovarian cancer) showed no difference, but the ones placed before surgery and was used during surgery did.

And agree, statistics lie. And also, all the clinical data is from retrospective analysis - the worst form of evidence.

However, the reason it probably works is that it decreases the use of peri-operative opioid use, and decrease the amount of gas used. Both have been shown as potent immune function inhibitors.

The perioperative period during resection of cancer is probably MUCH more important than what has ever been considered. It is during this time that cancer cells are seeded in the blood, and it is during that time that our immune system (and more specifically) our NK cells are functioning overtime.

Here are editorials on the subject. View attachment 18074View attachment 18075


Yeager has been looking at the immune function and opioids for a long time. He has found that opioids are potent inhibitors of much of the specific cells of the immune tree. Here is just one of the many articles he has written on the subject.

Here is an article I found absolutely fascinating. It discusses some of the proteins that cancers need to survice and seed and all that stuff, and shows how if you decrease opioid use (or use regional) you are able to maintain normal levels of NK and other immune function cells, and thus decrease the markers that presumably help cancers seed in distant locations.

And that isn't even the whole story. What is really amazing is that some tumors actually have mu receptors on them - and mu agonists make tumor cells proliferate and metastisize. Look at this crazy article. They did alot of cool stuff that I won't describe here, but it demonstrates some compeling evidence towards this whole idea.

It has been long known that patients with pancreatic cancer that get celiac plexus blocks live longer. It's probably because they use less opioids.

So, there is laboratory data and people and animal data that show that opioids (and gas) decrease immune function. There is data that shows that regional decrease tumor cell markers perio-operatively. There is way cool data that show that knock-out mice (no mu receptors) that get the tumor don't get metastatic lesions (and a bunch of other cool stuff in that article - ya got to read it). And finally, there is retrospective data that also indicates all this other stuff people have been writing about for years. I think it is fine if you don't want to change your practice. You can wait for the prospective data in 10 years. In my mind, there is little downside to using regional since I probably would have advocated for it without all that data.

great post 👍

 

[ssmallz]

Really great post epidural man, I stand corrected and now have more stuff to read 👍

 

[epidural man]

Really great post epidural man, I stand corrected and now have more stuff to read 👍

Thanks.

At least read that article about lung cancer and mice and mu opioid receptors. It's pretty cool all the stuff they did.

 

[Idiopathic]

Oh there is no question why it (possibly) decreases the risk of reoccurance of cancer. And it probably has little to do with post-op pain. In fact, the most recent retrospective analysis shows that epidurals placed after surgery for pain control (for ovarian cancer) showed no difference, but the ones placed before surgery and was used during surgery did.

And agree, statistics lie. And also, all the clinical data is from retrospective analysis - the worst form of evidence.

However, the reason it probably works is that it decreases the use of peri-operative opioid use, and decrease the amount of gas used. Both have been shown as potent immune function inhibitors.

The perioperative period during resection of cancer is probably MUCH more important than what has ever been considered. It is during this time that cancer cells are seeded in the blood, and it is during that time that our immune system (and more specifically) our NK cells are functioning overtime.

Here are editorials on the subject. View attachment 18074View attachment 18075


Yeager has been looking at the immune function and opioids for a long time. He has found that opioids are potent inhibitors of much of the specific cells of the immune tree. Here is just one of the many articles he has written on the subject.

Here is an article I found absolutely fascinating. It discusses some of the proteins that cancers need to survice and seed and all that stuff, and shows how if you decrease opioid use (or use regional) you are able to maintain normal levels of NK and other immune function cells, and thus decrease the markers that presumably help cancers seed in distant locations.

And that isn't even the whole story. What is really amazing is that some tumors actually have mu receptors on them - and mu agonists make tumor cells proliferate and metastisize. Look at this crazy article. They did alot of cool stuff that I won't describe here, but it demonstrates some compeling evidence towards this whole idea.

It has been long known that patients with pancreatic cancer that get celiac plexus blocks live longer. It's probably because they use less opioids.

So, there is laboratory data and people and animal data that show that opioids (and gas) decrease immune function. There is data that shows that regional decrease tumor cell markers perio-operatively. There is way cool data that show that knock-out mice (no mu receptors) that get the tumor don't get metastatic lesions (and a bunch of other cool stuff in that article - ya got to read it). And finally, there is retrospective data that also indicates all this other stuff people have been writing about for years. I think it is fine if you don't want to change your practice. You can wait for the prospective data in 10 years. In my mind, there is little downside to using regional since I probably would have advocated for it without all that data.

nice post. ive been using 10 year old data in 50 female patients to make my case for regional. will definitely look deeper into this stuff. thanks.

 

[sevoflurane]

Nice Review. We just need more human investigations in regards to tumor recurrence and the effects of epidurals in term of decreased stress response and immunomodulation + the inherent decreased use of narcotics in terms of immunosuppression and Mu/kappa receptive tumors. I found the effect of alpha-2 agonism and antagoinism with Rauwolscine interesting.

Certainly regional alone will never be a silver bullet, but perhaps may play a small role in decreasing the complex puzzle of cancer recurrence. Surgical stress/manipulation/seeding, pain, stress response, transfusion therapy, Cox-2 inhibition, statins, b-blockers, alpha antagonism, regional anesthesia, perioperative hypothermia are all potential targets during the time of surgery. We just need to prove it in humans.


http://www.ncbi.nlm.nih.gov/pubmed/20508494

But maybe timing matters:

http://journals.lww.com/anesthesiol...algesia_and_Cancer_Recurrence__Timing.44.aspx

http://journals.lww.com/anesthesiol...algesia_and_Cancer_Recurrence__Timing.45.aspx

Just need better long term studies, which unfortunately takes time.

When reading a little bit on the topic, I wondered about mu responsive small and large bowel tumors and the use of entereg (mu receptor antagoinist). Prolly woulndn't hurt and at the very least will get your small and large bowel function back to normal quicker as well as a faster discharge from the hospital.

Thanks for the links epi man. 👍

 

[sevoflurane]

In contrast to previous retrospective studies in the colon, breast, and prostate cancer surgery, the authors found that the use of epidural analgesia for perioperative pain control during colorectal cancer surgery was not associated with a decreased cancer recurrence; however, a potential benefit was observed in older patients. The benefit of regional anesthesia on cancer recurrence may thus depend on the specific tumor type.

Hmmmm....🙄