Re: Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial
We read with interest your article regarding the relationship between epidural analgesia and survival rates in patients undergoing major abdominal surgery for cancer. All surgeons are keen to explore any avenue which may improve outcomes, and your research is especially pertinent with regards to the recent introduction of “enhanced recovery after surgery” (ERAS) protocols. These are multi faceted interventions which have dramatically decreased the length of stay in post operative patients by reducing the physiological stress of surgery, and have been widely implemented, especially within the field of colorectal surgery. One of the key principles of ERAS is the minimisation of opiate usage, combined with the use of epidurals, to provide appropriate analgesia, whilst reducing the risk of post operative ileus. 1, 2. Therefore it would be beneficial if an intervention used to improve short term morbidity could also improve long term survival.
Unfortunately your article did not find a significant link between the use of epidural analgesia and survival rates, however the study group was very heterogeneous with regards to the operations performed, and the underlying primary cancer; it would be difficult to apply these results specifically, say to the field of colorectal surgery. There was also some vagueness with regards to the opiate usage post operatively; despite it being a multicentre study, the data regarding this has come from a single site, and therefore is questionable as to its validity. The hypothesis formed is based on the concept that morphine has an immunosuppressive affect, and therefore may promote tumour spread. It therefore seems critical to precisely know how much opiate was used in each group.
We therefore feel that this study raises some useful questions which merit further investigation, especially within the area of ERAS and colorectal cancer. Has the implementation of ERAS protocols which attempt to maintain a normal physiological state and therefore reduce the immunosuppressive effect of surgery improved disease free survival? As surgeons, it is critical to know the long term effects of our apparently short term decisions.
References
1. Abraham N, Albayati S. Enhanced recovery after surgery programs hasten recovery after colorectal resections. World Journal of Gastrointestinal Surgery. 2011; 3(1): 1-6
2. Fearon KCH, Ljungqqvist O, Von Meyenfeldt M, Revhaug A, Dejong CHC, Lassen K, Nygren J, Hausel J, Soop M, Anderson J, Kehlet H. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition. 2005; 24: 466-477
Competing interests:
No competing interests
12 December 2012
Ajit Dhillon
CT2 General Surgery
Alison Luther, Shahid Farid, Carolyn Patrick, Daniel Couch, Peter S Kang
Rapid Response:
Re: Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial
We read with interest your article regarding the relationship between epidural analgesia and survival rates in patients undergoing major abdominal surgery for cancer. All surgeons are keen to explore any avenue which may improve outcomes, and your research is especially pertinent with regards to the recent introduction of “enhanced recovery after surgery” (ERAS) protocols. These are multi faceted interventions which have dramatically decreased the length of stay in post operative patients by reducing the physiological stress of surgery, and have been widely implemented, especially within the field of colorectal surgery. One of the key principles of ERAS is the minimisation of opiate usage, combined with the use of epidurals, to provide appropriate analgesia, whilst reducing the risk of post operative ileus. 1, 2. Therefore it would be beneficial if an intervention used to improve short term morbidity could also improve long term survival.
Unfortunately your article did not find a significant link between the use of epidural analgesia and survival rates, however the study group was very heterogeneous with regards to the operations performed, and the underlying primary cancer; it would be difficult to apply these results specifically, say to the field of colorectal surgery. There was also some vagueness with regards to the opiate usage post operatively; despite it being a multicentre study, the data regarding this has come from a single site, and therefore is questionable as to its validity. The hypothesis formed is based on the concept that morphine has an immunosuppressive affect, and therefore may promote tumour spread. It therefore seems critical to precisely know how much opiate was used in each group.
We therefore feel that this study raises some useful questions which merit further investigation, especially within the area of ERAS and colorectal cancer. Has the implementation of ERAS protocols which attempt to maintain a normal physiological state and therefore reduce the immunosuppressive effect of surgery improved disease free survival? As surgeons, it is critical to know the long term effects of our apparently short term decisions.
References
1. Abraham N, Albayati S. Enhanced recovery after surgery programs hasten recovery after colorectal resections. World Journal of Gastrointestinal Surgery. 2011; 3(1): 1-6
2. Fearon KCH, Ljungqqvist O, Von Meyenfeldt M, Revhaug A, Dejong CHC, Lassen K, Nygren J, Hausel J, Soop M, Anderson J, Kehlet H. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition. 2005; 24: 466-477
Competing interests: No competing interests