title: Perioperative epidural analgesia reduces cancer recurrence after gastro-oesophageal surgery.
abstract: BACKGROUND
  Recent interest has focused on the role of perioperative epidural analgesia in improving cancer outcomes. The heterogeneity of studies (tumour type, stage and outcome endpoints) has produced inconsistent results. Clinical practice also highlights the variability in epidural effectiveness. We considered the novel hypothesis that effective epidural analgesia improves cancer outcomes following gastro-oesophageal cancer surgery in patients with grouped pathological staging.
  
  
  METHODS
  Following institutional approval, a database analysis identified 140 patients, with 2-year minimum follow-up after gastro-oesophageal cancer surgery. All patients were operated on by a single surgeon (2005-2010). Information pertaining to cancer and survival outcomes was extracted.
  
  
  RESULTS
  Univariate analysis demonstrated a 1-year 14% vs. 33% (P = 0.01) and 2-year 27% vs. 40% [hazard ratio (HR)=0.59; 95% CI, 0.32-1.09, P = 0.087] incidence of cancer recurrence in patients with (vs. without) effective (> 36 h duration) epidural analgesia, respectively. Multivariate analysis demonstrated increased time to cancer recurrence (HR = 0.33; 95% CI: 0.17-0.63, P < 0.0001) and overall survival benefit (HR = 0.42; 95% CI: 0.21-0.83, P < 0.0001) at 2-year follow-up following effective epidural analgesia. Subgroup analysis identified epidural-related cancer recurrence benefit in patients with oesophageal cancer (HR = 0.34; 95% CI: 0.16-0.75, P = 0.005) and in patients with tumour lymphovascular space infiltration (LVSI), (HR = 0.49; 95% CI: 0.26-0.94, P = 0.03). Effective epidural analgesia improved estimated median time to death (2.9 vs. 1.8 years, P = 0.029) in patients with tumour LVSI.
  
  
  CONCLUSIONS
  This study found an association between effective post-operative epidural analgesia and medium-term benefit on cancer recurrence and survival following oesophageal surgery. A prospective study that controls for disease type, stage and epidural effectiveness is warranted.
authors.affiliation: Department of Anaesthesia, The Royal Marsden, Chelsea, London, UK; Department of Cancer Anaesthesia and Pain Medicine, University of Melbourne, Australia.
authors.forename: J G
authors.initials: JG
authors.lastname: Hiller
authors.forename: M B
authors.initials: MB
authors.lastname: Hacking
authors.forename: E K
authors.initials: EK
authors.lastname: Link
authors.forename: K L
authors.initials: KL
authors.lastname: Wessels
authors.forename: B J
authors.initials: BJ
authors.lastname: Riedel
mesh_terms: D000368:Aged; D015360:Analgesia, Epidural; D004938:Esophageal Neoplasms / Q000453:epidemiology / Q000517:prevention & control* / Q000601:surgery*; D004947:Esophagus / Q000473:pathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D011446:Prospective Studies; D013270:Stomach / Q000473:pathology; D013274:Stomach Neoplasms / Q000453:epidemiology / Q000517:prevention & control* / Q000601:surgery*; D016019:Survival Analysis