• Br J Anaesth · Aug 2019

    Comment

    Propofol-based total intravenous anaesthesia is associated with better survival than desflurane anaesthesia in hepatectomy for hepatocellular carcinoma: a retrospective cohort study.

    Why is this important?

    Suspicions that anesthetic technique impacts survival after cancer surgery continues to be both unanswered and psychologically weighty: are anesthetic choices undermining patient survival?

    What did they do?

    This Taiwanese research group conducted a retrospective cohort-study in a single hospital covering 10 years of elective hepatectomy patients, comparing propofol to desflurane anesthesia. Notably, hepatocellular carcinoma is one of the leading causes of cancer death in Taiwan.

    And they found...?

    TIVA propofol was associated with a dramatically better survival (hazard ratio 0.57 (0.38-0.59)), even in subgroup analysis dependent on staging.

    Reality check

    Although this finding is consistent with other observational studies across a range of cancers, the apparent size of the benefit (50% mortality reduction!) should give us pause.

    Given inconsistent findings from a range of similar observational studies, it is unlikely that there is a real treatment effect of this magnitude.

    While we await results from well-powered RCTs, the jury is still out on whether anesthesia choices impact any specific cancer surgery...

    summary
    • Hou-Chuan Lai, Meei-Shyuan Lee, Chin Lin, Kuen-Tze Lin, Yi-Hsuan Huang, Chih-Shung Wong, Shun-Ming Chan, and Zhi-Fu Wu.
    • Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
    • Br J Anaesth. 2019 Aug 1; 123 (2): 151-160.

    BackgroundPrevious studies have shown that anaesthetic technique can affect outcomes of cancer surgery. We investigated the association between anaesthetic technique and patient outcomes after elective hepatectomy for hepatocellular carcinoma.MethodsThis was a retrospective single-centre cohort study of patients who received elective hepatectomy for hepatocellular carcinoma from January 2005 to December 2014. Patients were grouped according to propofol or desflurane anaesthesia. Kaplan-Meier analysis was performed and survival curves were constructed from the date of surgery to death. After propensity matching, univariable and multivariable Cox regression models were used to compare hazard ratios for death. Subgroup analyses were performed for tumour-node-metastasis staging and distant metastasis and local recurrence.ResultsA total of 492 patients (369 deaths, 75.0%) with desflurane anaesthesia and 452 (139 deaths, 30.8%) with propofol anaesthesia were eligible for analysis. After propensity matching, 335 patients remained in each group. In the matched analysis, propofol anaesthesia had a better survival with hazard ratio of 0.47 (95% confidence interval, 0.38-0.59; P<0.001). Subgroup analyses also showed significantly better survival in the absence of distant metastasis (hazard ratio, 0.47; 95% confidence interval, 0.37-0.60; P<0.001) or local recurrence (hazard ratio, 0.22; 95% confidence interval, 0.14-0.34; P<0.001) in the matched groups.ConclusionsPropofol anaesthesia was associated with better survival in hepatocellular carcinoma patients who underwent hepatectomy. Prospective studies are warranted to evaluate the effects of propofol anaesthesia on surgical outcomes in hepatocellular carcinoma patients.Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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    This article appears in the collection: Anesthesia technique and cancer recurrence.

    Notes

    summary
    1

    Why is this important?

    Suspicions that anesthetic technique impacts survival after cancer surgery continues to be both unanswered and psychologically weighty: are anesthetic choices undermining patient survival?

    What did they do?

    This Taiwanese research group conducted a retrospective cohort-study in a single hospital covering 10 years of elective hepatectomy patients, comparing propofol to desflurane anesthesia. Notably, hepatocellular carcinoma is one of the leading causes of cancer death in Taiwan.

    And they found...?

    TIVA propofol was associated with a dramatically better survival (hazard ratio 0.57 (0.38-0.59)), even in subgroup analysis dependent on staging.

    Reality check

    Although this finding is consistent with other observational studies across a range of cancers, the apparent size of the benefit (50% mortality reduction!) should give us pause.

    Given inconsistent findings from a range of similar observational studies, it is unlikely that there is a real treatment effect of this magnitude.

    While we await results from well-powered RCTs, the jury is still out on whether anesthesia choices impact any specific cancer surgery...

    Daniel Jolley  Daniel Jolley
     
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