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Journal of Peking University (Health Sciences) ›› 2021, Vol. 53 ›› Issue (6): 1152-1158. doi: 10.19723/j.issn.1671-167X.2021.06.024

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Epidural block associated with improved long-term survival after surgery for colorectal cancer: A retrospective cohort study with propensity score matching

MU Dong-liang1,XUE Cheng1,AN Bin2,WANG Dong-xin1,△()   

  1. 1. Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
    2. Department of Anesthesiology, Aerospace Center Hospital, Beijing 100049, China
  • Received:2019-12-26 Online:2021-12-18 Published:2021-12-13
  • Contact: Dong-xin WANG E-mail:wangdongxin@hotmail.com

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Abstract:

Objective: To investigate the effect of epidural anesthesia on the long-term prognosis of patients after selective colorectal cancer resection surgery. Methods: This was a retrospective cohort study and approved by local institution review board. Patients who underwent selective colorectal cancer resection surgery from August 2011 to December 2012 in Peking University First Hospital were enrolled. The patients were divided into general anesthesia (GA) group and combined epidural-general anesthesia (EGA) group according to anesthesia type. Primary outcome was patient’s long-term survival status. Secondary outcome included the overall incidence of in-hospital complications and length of postoperative in-hospital stay. Propensity score was used to match cases between the two groups based on the probability of receiving EGA. Survival was analyzed by Kaplan-Meier analysis and compared by Log-rank test between the two groups. Multivariate Cox regression analysis was used to investigate the relationship between epidural anesthesia and other variables with long-term survival status. Results: A total of 264 patients were entered into final analysis, including 166 cases in GA group and 98 cases in EGA group. Mean age of the patients was (63.3±12.1) years and mean survival time was 47.2 (95%CI 45.7-48.7) months. Before the propensity score match, the mortality in EGA group was 16.9% (28/166) and 9.2% (9/98) in GA group. But comparison between the two groups had no statistical significance (P=0.091). After the propensity score match,87 paired cases were matched and analyzed. The risk of long-term mortality in EGA group was lower than that of GA group by Kaplan-Meier analysis (5.7% vs.16.1%, HR=0.344, 95%CI 0.124-0.955, P=0.041). Mean survival time of EGA group was longer than that of GA group (50.3 months vs. 42.9 months, P=0.032). Multivariate Cox regression ana-lysis showed that EGA, in comparison with GA, was related with lower risk of long-term mortality (HR=0.326, 95%CI 0.117-0.909, P=0.032). Age (HR=1.042, 95%CI 1.001-1.085, P=0.046) and preoperative lymph node metastasis (HR=2.924, 95%CI 1.162-7.356, P=0.023) were also related with increased risk of long-term mortality. Conclusion: Present study found that perioperative use of epidural anesthesia and analgesia was associated with improvement of the patient’s long-term survival. Well-designed studies are needed to verify this hypothesis.

Key words: General anesthesia, Epidural anesthesia, Colorectal cancer, Long-term, Survival status

CLC Number: 

  • R614.4

Table 1

Baseline characteristic of all patients"

Variables All patients
(n=264)		 Before matching After matching
GA group
(n=166)		 EGA group
(n=98)		 P GA group
(n=87)		 EGA group
(n=87)		 P
Age/year, $\overline{x}$±s 63.3±12.1 64.2±12.7 61.6±10.9 0.082 61.2±12.8 60.5±10.5 0.698
BMI, $\overline{x}$±s 23.8±3.3 23.8±3.6 23.7±2.8 0.749 24.2±3.7 23.7±2.8 0.360
Preoperative comorbidity, n (%)
CAD 37 (14.0) 29 (17.5) 8 (8.2) 0.035 4 (4.6) 5 (5.7) 1.000
Hypertension 117 (44.3) 82 (49.4) 35 (35.7) 0.031 38 (43.7) 29 (33.3) 0.161
Stroke 26 (9.8) 21 (12.7) 5 (5.1) 0.047 6 (6.9) 2 (2.3) 0.148
Diabetics 45 (17.0) 33 (19.9%) 12 (12.2) 0.111 11 (12.6) 8 (9.2) 0.466
CRF 6 (2.3) 6 (3.6) 0 (0) 0.057 2 (2.3) 0 (0) 0.155
COPD 6 (2.3) 2 (1.2) 4 (4.1) 0.130 2 (2.3) 3 (3.4) 1.000
ASA grade, n (%) 0.008 0.794
1 21 (8.0) 10 (6.0) 11 (11.2) 9 (10.3) 11 (12.6)
2 188 (71.2) 111 (66.9) 77 (78.6) 76 (87.4) 73 (83.9)
3 55 (20.9) 44 (26.5) 10 (10.2) 2 (2.3) 3 (3.4)
Surgery site, n (%) 0.759 0.762
Colon 118 (44.7) 73 (44.0) 45 (45.9) 45 (51.7) 43 (49.4)
Rectal 146 (55.3) 93 (56.0) 53 (54.1) 42 (48.3) 44 (50.6)
Anesthesia time/h, $\overline{x}$±s 5.5±1.7 5.4±1.8 5.5±1.7 0.877 5.7±1.6 5.5±1.6 0.595
Allogenic blood transfusion, n (%) 14 (5.3) 10 (6.0) 4 (4.1) 0.496 1 (1.1) 3 (3.4) 0.312
Tumor size, n (%) (n=259) (n=162) (n=97) 0.601 0.931
<2 cm 13 (4.9) 7 (4.2) 6 (6.1) 5 (5.7) 5 (5.7)
2-<3 cm 49 (18.6) 29 (17.5) 20 (20.4) 18 (20.7) 18 (20.7)
3-<5 cm 117 (44.3) 71 (42.8) 46 (46.9) 38 (43.7) 42 (48.3))
5-<7 cm 50 (18.9) 36 (21.7) 14 (14.3) 15 (17.2) 11 (12.6)
≥7 cm 30 (11.4) 19 (11.4) 11 (11.2) 11 (12.6) 11 (12.6)
Pathological grade, n (%) 0.158 0.346
Undifferentiation 1 (0.4) 0 (0) 1 (1.0) 0 (0) 1 (1.1)
Low differentiation 29 (11.0) 16 (9.6) 13 (13.3) 7 (8.0) 12 (13.8)
Medium differentiation 204 (77.3) 125 (75.3) 79 (80.6) 67 (77.0) 70 (80.5)
Well differentiation 5 (1.9) 1 (0.6) 4 (4.1) 1 (1.1) 4 (4.6)
Not available 25 (9.5) 24 (14.5) 1 (1.0) 12 (13.8) 0 (0)
Lymph node metastasis, n (%) 123 (46.6) 85 (51.2) 38 (38.8) 0.060 31 (35.6) 34 (39.1) 0.638
Postoperative radio-/chemotherapy, n (%) 132 (50.4)
(n=263)		 81 (48.8)
(n=166)		 51 (53.1)
(n=97)		 0.411 42 (48.3) 49 (56.3) 0.288

Table 2

Primary and secondary outcomes"

Variables Before matching After matching
GA group
(n=166)		 EGA group
(n =98)		 P GA group
(n =87)		 EGA group
(n =87)		 HR, OR or difference
(95%CI)		 P
Primary outcome
Overall survival, death, n (%) 28 (16.9) 9 (9.2) 0.091 14 (16.1) 5 (5.7) HR=0.34 (0.12, 0.96) 0.041
Secondary outcome, n (%)
Total incidence of complications 32 (19.3) 10 (10.2) 0.052 16 (18.4) 7 (8.0) OR=0.39 (0.15, 1.00) 0.044
Individualized complications
Ischemic cardiac events 2 (1.2) 0 (0) 0.531 1 (1.1) 0 (0) OR=0.99 (0.97, 1.01) 1.000
Hypertension 24 (14.5) 5 (5.1) 0.019 12 (13.8) 4 (4.6) OR=0.30 (0.09, 0.97) 0.036
Heart failure 3 (1.8) 0 (0) 0.297 2 (2.3) 0 (0) OR=0.98 (0.95, 1.10) 0.497
Arrythmia 4 (2.4) 3 (3.1) 0.713 0 (0) 1 (1.1) OR=1.01 (0.99, 1.04) 1.000
Atelectasis 1 (0.6) 0 (0) 1.000 1 (1.1) 0 (0) OR=0.99 (0.97, 1.01) 1.000
Pneumonia 2 (1.2) 1 (1.0) 1.000 1 (1.1) 1 (1.1) OR=1.00 (0.06, 16.25) 0.751
Hydrothorax 5 (3.0) 0 (0) 0.161 3 (3.4) 0 (0) OR=0.97 (0.93, 1.01) 0.246
Deep venous thrombi 0 (0) 2 (2.0) 0.137 0 (0) 2 (2.3) OR=1.02 (0.99, 1.06) 0.497
Postoperative LOS/day, median (IQR) 11 (9, 14) 11 (9, 14) 0.810 11 (9, 13) 11 (9, 14) Difference=0 (-1.0, 1.0) 0.783

Figure 1

Kaplan-Meier analysis A, Kaplan-Meier analysis before propensity score match. Mean survival time had no statistical difference between GA and EGA groups (42.1 months vs. 48.9 months, P=0.085); B, Kaplan-Meier analysis after propensity score match. Mean survival time in EGA group was longer than that of GA group (50.3 months vs. 42.9 months, P=0.032). GA, general anesthesia; EGA, combined epidural-general anesthesia."

Table 3

Multivariate Cox regression analysis"

Variables Before matching After matching
Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
HR (95%CI) P HR (95%CI) P HR (95%CI) P HR (95%CI) P
Agea 1.04 (1.01, 1.07) 0.005 1.04 (1.02, 1.07) 0.001 1.04 (1.00, 1.08) 0.070 1.04 (1.00, 1.09) 0.046
Body mass indexb 0.88 (0.79, 0.98) 0.015
Coronary artery diseasec 2.25 (1.06, 4.77) 0.035
Diabeticsc 1.86 (0.90, 3.84) 0.095
Chronic renal failurec 4.32 (1.32, 14.10) 0.015 4.27 (1.49, 12.27) 0.007
ASA physical graded 2.28 (1.29, 4.41) 0.004
EGA groupe 0.52 (0.25, 1.11) 0.091 0.53 (0.28, 0.98) 0.044 0.34 (0.12, 0.96) 0.041 0.33 (0.12, 0.91) 0.032
Pathological gradef 0.49 (0.24, 1.03) 0.061 0.42 (0.24, 0.72) 0.002
Tumor sizeg 1.02 (1.00, 1.04) 0.076
Lymph node metastasisc 2.23 (1.11, 4.49) 0.024 2.81 (1.48, 5.34) 0.02 2.44 (0.98, 6.06) 0.056 2.92 (1.16, 7.36) 0.023
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