Surgical approach and the impact of epidural analgesia on survival after esophagectomy for cancer: A population-based retrospective cohort study.

Autor: Cummings Iii KC; Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States of America.; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Anesthesiology, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America., Kou TD; Department of Quantitative and Population Health Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America., Chak A; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America., Schluchter MD; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Quantitative and Population Health Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America., Margevicius S; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Quantitative and Population Health Sciences, Case Western Reserve University, Cleveland, Ohio, United States of America., Cooper GS; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America., Meropol NJ; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America., Perry Y; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.; Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America., Linden PA; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.; Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America., Cummings LC; Case Comprehensive Cancer Center, Cleveland, Ohio, United States of America.; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America.; Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America.
Jazyk: angličtina
Zdroj: PloS one [PLoS One] 2019 Jan 22; Vol. 14 (1), pp. e0211125. Date of Electronic Publication: 2019 Jan 22 (Print Publication: 2019).
DOI: 10.1371/journal.pone.0211125
Abstrakt: Background: Esophagectomy for esophageal cancer carries high morbidity and mortality, particularly in older patients. Transthoracic esophagectomy allows formal lymphadenectomy, but leads to greater perioperative morbidity and pain than transhiatal esophagectomy. Epidural analgesia may attenuate the stress response and be less immunosuppressive than opioids, potentially affecting long-term outcomes. These potential benefits may be more pronounced for transthoracic esophagectomy due to its greater physiologic impact. We evaluated the impact of epidural analgesia on survival and recurrence after transthoracic versus transhiatal esophagectomy.
Methods: A retrospective cohort study was performed using the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Patients aged ≥66 years with locoregional esophageal cancer diagnosed 1994-2009 who underwent esophagectomy were identified, with follow-up through December 31, 2013. Epidural receipt and surgical approach were identified from Medicare claims. Survival analyses adjusting for hospital esophagectomy volume, surgical approach, and epidural use were performed. A subgroup analysis restricted to esophageal adenocarcinoma patients was performed.
Results: Among 1,921 patients, 38% underwent transhiatal esophagectomy (n = 730) and 62% underwent transthoracic esophagectomy (n = 1,191). 61% (n = 1,169) received epidurals and 39% (n = 752) did not. Epidural analgesia was associated with transthoracic approach and higher volume hospitals. Patients with epidural analgesia had better 90-day survival. Five-year survival was higher with transhiatal esophagectomy (37.2%) than transthoracic esophagectomy (31.0%, p = 0.006). Among transthoracic esophagectomy patients, epidural analgesia was associated with improved 5-year survival (33.5% epidural versus 26.5% non-epidural, p = 0.012; hazard ratio 0.81, 95% confidence interval [0.70, 0.93]). Among the subgroup of esophageal adenocarcinoma patients undergoing transthoracic esophagectomy, epidural analgesia remained associated with improved 5-year survival (hazard ratio 0.81, 95% confidence interval [0.67, 0.96]); this survival benefit persisted in sensitivity analyses adjusting for propensity to receive an epidural.
Conclusion: Among patients undergoing transthoracic esophagectomy, including a subgroup restricted to esophageal adenocarcinoma, epidural analgesia was associated with improved survival even after adjusting for other factors.
Competing Interests: The authors have declared that no competing interests exist.
Databáze: MEDLINE
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