Intraoperative nociception and postoperative inflammation associated with the suppression of major complications due to thoracic epidural block after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia: A retrospective observational study

Our plain-English summary of Intraoperative nociception and postoperative inflammation associated with the suppression of major complications due to thoracic epidural block after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia: A retrospective observational study, by Y. Hamanaka, W. Ueda, K. Taki, et al (Medicine, 2023).

The study

• Authors: Y. Hamanaka, W. Ueda, K. Taki, K. Onoe, Y. Matsuki, H. Okutani, R. Ueki, M. Hirose
• Journal: Medicine
• Published: 2023;102(35):e34832
• Read it: PubMed · Publisher · Free full text

Abstract

A recent study showed that thoracic epidural block (TEB) suppressed the occurrence of major complications after pleurectomy/decortication (P/D) for malignant pleural mesothelioma (MPM) under general anesthesia. To investigate the mechanisms underlying the correlation, both acute inflammatory status and intraoperative nociception were evaluated in the present study. In a single-institutional observational study, consecutive adult patients undergoing P/D were enrolled from March 2019 to April 2022. Perioperative acute inflammatory status was evaluated using differential White blood cell (WBC) counts and serum concentration of C-reactive protein (CRP) both before and after the surgery on postoperative day (POD) 1. The averaged value of nociceptive response index during surgery (mean NR) was obtained to evaluate the level of intraoperative nociception. Multivariable logistic regression analysis was performed to determine the association between perioperative variables and major complications Postoperative major postoperative complication was defined as Clavien-Dindo grades ≥ III. We conducted this study with 97 patients. After logistic regression analysis showed that general anesthesia without TEB was a sole risk factor for major complications, patients were divided into 2 groups: general anesthesia with and without TEB. The incidence of major complications was significantly lower in patients with TEB (33.3%, n = 33) than in those without TEB (64.1%, n = 64, P < .01). Although there was no significant difference in the CRP level between 2 groups, the lymphocyte-to-monocyte ratio (LMR) on POD 1 in patients with TEB was significantly higher than that in patients without TEB (P = .04). The mean NR was significantly lower in patients with TEB than that in those without TEB (P = .02). Both lower mean NR during surgery and higher LMR on POD 1 are likely associated the suppression of major complications due to TEB after P/D under general anesthesia. Decreases in the postoperative acute inflammatory response, caused by the reduction of intraoperative nociception due to TEB, may help suppress major complications after P/D.

Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

In plain English

This retrospective observational study at Hyogo Medical University Hospital in Japan looked at 97 adults who had pleurectomy/decortication, an operation for malignant pleural mesothelioma, between March 2019 and April 2022. It did not examine asbestos exposure. The authors compared 33 patients who received a thoracic epidural block (a pain-relief catheter in the back) along with general anesthesia against 64 who had general anesthesia alone. Anesthesiologists decided who received the epidural. Major complications within 30 days, most often air leaks, occurred in 33.3% of the epidural group and 64.1% of the other group. In a multivariable analysis, the epidural was linked to lower odds of major complications (odds ratio 0.23, 95% CI 0.09 to 0.60). The epidural group had a lower average nociceptive response index during surgery, a measure of the body's reaction to surgical stimulation. On the day after surgery it had a higher lymphocyte-to-monocyte ratio, a blood marker of inflammation. C-reactive protein did not differ significantly. The authors concluded that less intraoperative nociception and less inflammation may help explain the fewer complications, and they called for a randomized trial.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Single-institution retrospective observational study using medical records; epidural use was not randomized
• Who was studied: 122 consecutive adults who had pleurectomy/decortication for malignant pleural mesothelioma at Hyogo Medical University Hospital, Japan, March 2019 to April 2022. 25 were excluded for missing data, leaving 97 analyzed: 33 with and 64 without thoracic epidural block.
• Exposure: No asbestos exposure was studied. The comparison was general anesthesia with thoracic epidural block (levobupivacaine and fentanyl infusion) versus general anesthesia without it. The epidural was given at the attending anesthesiologist's discretion.
• Main results:
  • Major complications (Clavien-Dindo grade III or higher) occurred in 11 of 33 patients with epidural block (33.3%) and 41 of 64 without it (64.1%), P less than 0.01, according to Table 3.
  • In multivariable logistic regression, thoracic epidural block was associated with lower odds of major complications: odds ratio 0.23 (95% CI 0.09 to 0.60). No other candidate variable was significant.
  • Air leak was the most common major complication (n = 45), followed by respiratory failure (n = 5).
  • Mean intraoperative nociceptive response index was lower with epidural block (0.846, SD 0.017) than without (0.856, SD 0.022), P = 0.02.
  • Lymphocyte-to-monocyte ratio on postoperative day 1 was higher with epidural block (1.7, SD 0.7) than without (1.5, SD 0.8), P = 0.04.
  • Serum C-reactive protein on postoperative day 1 did not differ significantly between the groups: 5.57 mg/dL without epidural versus 5.35 mg/dL with epidural, P = 0.48.
  • Remifentanil infusion dose and total fentanyl dose during anesthesia were significantly lower in the epidural group.
• The authors' conclusion: The authors concluded that lower intraoperative nociception and a higher lymphocyte-to-monocyte ratio on postoperative day 1 are likely correlated with fewer major complications in patients with thoracic epidural block. They suggested that a reduced postoperative acute inflammatory response may help suppress major complications after pleurectomy/decortication.
• Limitations the authors state:
  • The study was retrospective and observational, based on perioperative data.
  • Fewer patients were analyzed than in the authors' earlier study because of a large volume of missing differential white blood cell counts. Most patients were also included in that earlier study.
  • The authors stated that a prospective randomized controlled study is needed to determine the mechanisms.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Inflammation, Pleurectomy/Decortication (P/D), Pleural Mesothelioma.

Related studies

• Influence of the effectiveness of sarcopenia on postoperative major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy: a retrospective cohort study — N. Havan, S. Gülmez, et al. (2025)
• Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications — R.J. Torphy, C. Stewart, et al. (2020)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Postoperative Analgesia and Length of Hospital Stay After Surgery for Malignant Pleural Mesothelioma: A Retrospective Observational Study — M. Kobata, K. Takeda, et al. (2024)
• A preclinical model to investigate the role of surgically-induced inflammation in tumor responses to intraoperative photodynamic therapy — R.W. Davis, E. Papasavvas, et al. (2018)
• Awake Thoracic Surgery with Thoracic Epidural Anesthesia in High-Risk Patients: Three Case Reports and Clinical Insights — S. Kesici, F. Uysal, et al. (2025)

Browse more research in Medicine, or return to medical research.