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Perioperative immune function is important for the development of cancer recurrence and surgical site infection.
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Use of regional anesthesia-analgesia (with a local anesthetic-based regimen) as part of a multidisciplinary approach may attenuate perioperative immunosuppression and provide the physiologic basis for decreasing cancer recurrence and surgical site infection.
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Currently available data examining the relationship between regional anesthesia-analgesia and decreasing cancer recurrence or
Regional Anesthesia-Analgesia: Relationship to Cancer Recurrence and Infection
Section snippets
Key points
The immune system and cancer
The hypothesis that the immune system is responsible for cancer elimination and suppression is not new.1 Individuals with suppressed immune systems, such as those with human immunodeficiency virus or requiring immunosuppressive agents after organ transplantation, show increased risks of cancer development.2, 3, 4 A properly functioning immune system is vital in reducing cancer occurrence for the individual. However, the interplay between the immune system and cancer cells is complex and has led
Surgical stress leads to immunosuppression via stress response
Once tumors are present, surgical excision is often offered as a major treatment option. However, surgery is not often curative because minimal residual disease, either at the tumor margins or at micrometastases at distant sites, can be present. Surgery may actually increase growth in previously unrecognized micrometastases and create an environment that promotes further metastatic spread.6 As these remaining cancer cells continue to divide, the cellular immune response is often weakened within
Opioids and the immune system
Opioid medications, routinely used as the mainstay of postsurgical analgesia, are themselves not benign and can exert effects on the immune system. Morphine has been shown to inhibit natural killer cell cytotoxicity in healthy volunteers.13 In addition, fentanyl, a synthetic opioid unrelated to morphine, has also been shown to inhibit natural killer cell function during the perioperative period.14 There are even data that suggest that morphine may play a proangiogenic role and promote breast
Regional anesthesia and local anesthetic effects on immunosuppression
Regional anesthesia has long been considered an alternative to general anesthesia (GA) or a supplement with particular use in the postoperative period. Although opioids have a complex interaction with the stress response following surgery and the subsequent immune effects, regional anesthesia when using a local anesthetic-based solution has been shown repeatedly to attenuate the surgical stress response.20 Furthermore, both intraoperative and postoperative use of a thoracic epidural for
Studies investigating the relationship between regional anesthesia and cancer recurrence
There are several studies that have examined the relationship between regional anesthesia-analgesia and cancer recurrence (Table 1). All of these studies have been published within the past decade and in essence are observational studies (ie, prospective/retrospective cohort from a database or a reanalysis of data from previously published randomized controlled studies). There is no definitive answer to this question because there are significant methodologic flaws in the available studies,
Meta-analyses
There have been limited attempts to perform a meta-analysis based on the available studies and literature. However, the lack of data as well as type of studies done, which are mainly observational and secondary analyses of RCTs, makes it difficult to draw definite associations. This challenge is compounded by the heterogeneity of data, such as the numerous types of surgeries and tumors included, as well as the many definitions of “recurrence.”
In 2012, Chen and colleagues42 performed a
Surgical site infections and regional anesthesia
SSIs continue to be one of the most serious complications during the perioperative period. Roughly 157,500 SSIs occur annually, resulting in increased length of stay and hospital readmission.44 Overall incidence of SSI is thought to be around 1% to 3%, but the risk for colorectal surgery can be as high as 15% to 35%.45 Although many SSIs can be prevented, patients that do develop a SSI have a significantly increased mortality compared with patients who do not develop a SSI.46
The immunologic
Summary
Perioperative immune function is important for the prevention of cancer recurrence and SSI in surgical patients who typically experience a transient period of immunosuppression. Although there are many potential inputs into perioperative immunosuppression, the use of regional anesthesia-analgesia with a local anesthetic-based regimen may attenuate the surgical stress response and preserve perioperative immune function. Other advantages of using perioperative regional anesthesia-analgesia are
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