Survival After Colorectal Cancer Surgery Better With Peridural Analgesia

May 08, 2013

By Robert Saunders

NEW YORK (Reuters Health) May 08 - Peridural analgesia administered during colorectal cancer resection and postoperatively is associated with improved long-term survival rates, researchers in Germany report.

"The present results are consistent with the theory that peridural analgesia may improve survival by decreasing the immunosuppressive effects of surgery and general anesthesia," they wrote in the Annals of Surgery online April 26.

In comments emailed to Reuters Health, lead author Dr. Marco Gruss added, "This study clearly indicates that the type of anesthesia might have long-term consequences for patients' outcome beyond the immediate postoperative period. These results have to be verified but we think that a regional anesthesia regime should be offered to all patients without contraindications."

Dr. Gruss, at Klinikum Hanau GmbH in Hanau am Main, and colleagues say previous studies have suggested that patients with various types of cancer benefit from peridural analgesia during surgery, but it is unclear if this includes colorectal cancer patients.

To investigate, the team analyzed data recorded in a prospective cancer registry on 749 patients who underwent surgery for colorectal cancer from 2003 to 2009.

After consultation with an anesthesiologist, 442 of the patients opted to have a peridural catheter placed for pain control during surgery and afterward; the other 307 patients declined or had contraindications.

Overall, five-year survival rates were 62% among patients who received peridural analgesia compared to 54% among those who did not (p=0.02). After adjustment for confounding variables, this translated to a mortality hazard ratio of 0.73 for patients who received peridural analgesia.

But the survival benefit was confined mainly to patients with greater medical morbidity, the team found. That is, survival was significantly greater for patients with American Society of Anesthesiologists (ASA) classification 3-4 (p<0.009) but not for patients with ASA grade 1-2.

"Patients who have increased morbidity (ASA classification 3 to 4) may be more susceptible to impairment of the immune system and these patients may benefit the most from the effects of peridural analgesia in reducing the immunosuppressive effects of surgery," Dr. Gruss and colleagues suggest.

"The mechanisms for the benefit we have observed in our study remain to be clarified," co-author Dr. Julia Holler, at University Hospital Giessen, commented via email. "What we know so far is that use of peridural analgesia perioperatively leads to less pain and stress in the postoperative course. Consequently, systemic opioid application perioperatively could be reduced. Opioids have shown a proangiogenic effect and a promotion of tumor growth in animal and clinical studies. This may provide a mechanism how PDA (peridural analgesia) can influence the long-term survival in patients with colorectal cancer."

She added, "Another hypothesis is that regional anesthesia can inhibit tumor growth and metastasis by a so-far unknown mechanism. However, it is more likely that these are only mosaic stones in a larger picture of a multifactorial model where other potential targets such as the immune system and inflammatory response are modulated by PDA."

Summing up, the investigators conclude in their paper, "The finding that peridural analgesia may improve long-term survival in patients with cancer is of great clinical interest and warrants further randomized controlled trials."

As Dr. Holler pointed out, this and other studies on the topic are retrospective, "so we cannot prove cause-and-effect relationship. This should be proved in randomized controlled trials."

Another co-author, Dr. Winfried Padberg, also at University Hospital Giessen, drew a more general lesson from the findings: "Multimodal concepts are nowadays the gold standard of surgical oncology," he observed. "The modalities include surgery, chemotherapy or radiotherapy in different adjuvant or neoadjuvant settings. Now we have learned from our study that additional factors during the perioperative course may influence long-term survival in patients with colorectal cancer. This study highlights the ultimate need for a multidisciplinary approach for the treatment of patients with cancer -- including the interaction between surgery and anesthesia."


Ann Surg 2013.


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