【罂粟摘要】硬膜外-全身联合麻醉与单独全身麻醉后患者的长期生存率比较:一项随机试验的随访
硬膜外-全身联合麻醉与单独全身麻醉后患者的长期生存率比较:一项随机试验的随访
贵州医科大学 高鸿教授课题组
翻译：任文鑫 编辑：佟睿 审校：曹莹
实验和观察研究表明，硬膜外-全身联合麻醉可通过减少麻醉剂和阿片类药物的消耗，以及钝化手术相关的炎症来改善癌症患者手术后的长期生存率。因此，本研究检验了硬膜外-联合全身麻醉能改善老年患者长期生存的主要假设。
本文介绍了在五家医院进行的先前试验中登记患者的长期随访。年龄在60岁至90岁之间，计划进行重大非心脏，胸腔和腹部手术的患者被随机分配到硬膜外-全身联合麻醉及术后硬膜外镇痛或单独全身麻醉及术后静脉镇痛。主要观察指标是术后总生存率。次要观察指标包括癌症特异性、无复发和无事件生存率。
在1802名被纳入基础试验并随机分组的患者中，1712名被纳入长期分析；92%有癌症生存率。中位随访时间为66个月（四分位数范围为61至80）。在接受硬膜外-全身联合麻醉的患者中，853例患者中有355例（42%）死亡，而单独接受全身麻醉的859例患者中有326例（38%）死亡：调整后的危险比为1.07；95%可信区间为0.92～1.24；P=0.408。硬膜外-全身联合麻醉（327/853[38%]）和单纯全身麻醉（292/859[34%]）的癌症特异性生存率相似：调整后的危险比为1.09；95%可信区间为0.93～1.28；P=0.290。硬膜外-全身联合麻醉的853例患者中，无复发生存率为401例[47%]，而单纯全身麻醉的859例患者中，无复发生存率为389例[45%]：调整后的危险比为0.97；95%可信区间为0.84～1.12；P=0.692。硬膜外-全身联合麻醉患者的无事件生存率为466/853[55%]，而单纯全身麻醉患者的无事件生存率为450/859[52%]：调整后的危险比为0.99；95%可信区间为0.86～1.12；P=0.815。
在胸部和腹部有严重创伤的老年患者中，硬膜外-全身麻醉联合硬膜外镇痛不能改善总体或癌症特异性长期死亡率。硬膜外镇痛也不能提高无复发生存率。因此，可以根据患者和临床医生的偏好合理选择这两种方法。
Ya-Ting Du, Ya-Wei Li, Bin-Jiang Zhao,et al.Long-term Survival after Combined Epidural–General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial.ANESTHESIOLOGY 2021; 135:233–45.
Long-term Survival after Combined Epidural–General Anesthesiaor General Anesthesia Alone: Follow-up of a Randomized Trial
Background: Experimental and observational research suggests that combined epidural–general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural–general anesthesia improves long-term survival in elderly patients.
Methods: This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural–general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival.
Results: Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural–general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural–general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural–general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural–general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815.
Conclusions: In elderly patients having major thoracic and abdominal surgery, combined epidural–general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference.