An assessment of the survival impact of multimodal anesthesia/analgesia technique in adults undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched analysis

Figures & data

Table 1. Baseline and perioperative characteristics of 373 patients with appendiceal carcinomatosis grouped according to the type of anesthetic management (multimodal anesthesia versus volatile-opioid).

	Entire study population			Matched covariates
	MA group (n = 110)	VO group (n = 263)	p Value	MA group (n = 107)	VO group (n = 107)	Standardized difference (%)
Age, years	–	–	.035	–	–	–
Mean ± SD	55 ± 11	53 ± 10	–	55 ± 10	54 ± 10	–
Median (IQR)	55 (50, 63)	53 (45, 61)	–	55 (48, 62)	54 (50, 61)	7.81
Gender, n (%)	–	–	.585	–	–	–
Female	64 (58)	161 (61)	–	62 (58)	61 (57)	–
Male	46 (42)	102 (39)	–	45 (42)	46 (43)	1.88
ASA score, n (%)	–	–	.032	–	–	–
II	11 (10)	50 (19)	–	11 (10)	10 (9)	–
III/IV	99 (90)	213 (81)	–	96 (90)	97 (91)	3.13
Body mass index	–	–	.764	–	–	2.34
Mean ± SD	28 ± 6	29 ± 6	–	28 ± 6	28 ± 6	–
Median (IQR)	27 (24, 31)	28 (24, 31)	–	28 (24, 32)	28 (24, 32)	–
Charleson comorbidity index, n (%)	–	–	.099	–	–	–
2	30 (27)	95 (36)	–	–	–	–
≥3	80 (73)	168 (64)	–	–	–	–
Tumor grade, n (%)	–	–	.009	–	–	–
Low	58 (53)	177 (70)	–	58 (54)	60 (56)	–
Intermediate	31 (28)	45 (18)	–	30 (28)	28 (26)	–
High	20 (18)	31 (12)	–	19 (18)	19 (18)	2.42
Extra abdominal disease, n (%)	–	–	.698	–	–	–
No	107 (97)	258 (98)	–	104 (97)	104 (97)	–
Yes	3 (3)	5 (2)	–	3 (3)	3 (3)	0
Neoadjuvant chemotherapy, n (%)	–	–	.018	–	–	–
No	–	–	–	62 (58)	61 (57)
Yes	62 (56)	182 (69)	–	45 (42)	46 (43)	1.88
	48 (44)	81 (31)	–	–	–	–
Preoperative NLR	–	–	.37	–	–	–
Mean (± SD)	2.4 ± 1.8	2.5 ± 1.9	–	–	–	–
Preoperative PLR	–	–	.121	–	–	–
Mean ± SD	157 ± 68	179 ± 120	–	158 ± 69	158 ± 82	0.52
PCI Score	–	–	.897	–	–	–
Mean ± SD	18 ± 10	18 ± 9		–	–	–
CC score, n (%)	–	–	.746	–	–	–
0	76 (70)	132 (67)	–	–	–	–
1	22 (20)	48 (24)	–	–	–	–
2	9 (8)	13 (7)	–	–	–	–
3	1 (1)	4 (2)	–	–	–	–
Anesthesia duration, min	–	–	.202	–	–	–
Mean ± SD	620 ± 143	643 ± 158	–	–	–	–
Estimated blood loss, ml	–	–	.412	–	–	–
Mean ± SD	587 ± 530	640 ± 587	–	588 ± 535	574 ± 577	2.49
Intraoperative opioids, MED	–	–	<.001	–	–	–
Mean ± SD	13 ± 10	194 ± 789	–	–	–	–
Median (IQR)	12 (8, 15)	114 (67, 170)	–	–	–	–
Epidural analgesia, n (%)	–	–	.01	–	–	–
No	21 (19)	25 (10)	–	–	–	–
Yes	89 (81)	238 (90)	–	–	–	–
Intraperitoneal chemotherapy, n ( %)	–	–	.065	–	–	–
Cisplatin	5 (4)	2 (1)	–	–	–	–
Mitomycin C	102 (93)	253 (96)	–	–	–	–
Oxaliplatin	3 (3)	8 (3)	–	–	–	–
NLR postoperative day 1	–	–	–	–	–	–
Mean ± SD	12.9 ± 10.2	14.1 ± 9.5	–	–	–	–
PLR postoperative day 1	–	–	.002	–	–	–
Mean ± SD	271 ± 160	318 ± 177	–	–	–	–
Length of stay, days	–	–	<.001	–	–	–
Mean ± SD	17 ± 23	21 ± 14	–	–	–	–
Median (IQR)	11 (9, 17)	16 (12, 24)	–	–	–	–

ASA: American society of anesthesiologists, completeness of cytoreduction score; 0 = no visible disease after cytoreduction, 1 = nodules < 2.5 cm, 2 = nodules 2.5 to 5 cm, 3 = nodules > 5 cm or confluence of unresectable tumor; IQR: interquartile range; MED: morphine equivalent dose; NLR: neutrophil:lymphocyte ratio; PCI: peritoneal carcinomatosis index; PLR: platelet:lymphocyte ratio; SD: standard deviation; MA: multimodal anesthesia; VO: volatile-opioid anesthesia.

Figure 1. Kaplan–Meier curves showing the progression free survival of patients who received volatile-opioid anesthesia and those who received multimodal anesthesia (MA).

Table 2. Multivariate Cox Proportional Hazards Model for progression free survival.

	Unmatched HR 95% CI, p value	After propensity score matching HR 95% CI, p value
Preoperative PLR (for every 10 unit increment)	1.07 (1.00, 1.03), .049	1.02 (0.99, 1.05), .099
Tumor grade
High versus low	2.91 (1.79, 4.73), <.001	2.27 (1.19, 4.34), .013
Intermediate versus low	2.14 (1.42, 3.22), <.001	2.02 (1.14, 3.58), .016
Extraabdominal disease
Yes versus no	1.71 (0.73, 4.01), .219	1.95 (0.64, 5.95), .239
Neoadjuvant chemotherapy: Yes versus no	2.15 (1.47, 3.16), <.001	2.85 (1.66, 4.88), <.001
Estimated blood loss (for every 50 ml increase)	1.03 (1.02, 1.05), <.001	1.03 (1.01, 1.05), .014
Anesthetic management: MA versus VO	1.22 (0.85, 1.76), .282	1.45 (0.94, 2.22), .093

CI: confidence interval; HR: hazard ratio; PLR: platelet:lymphocyte ratio; MA: multimodal anesthesia; VO: volatile-opioid anesthesia.

Figure 2. Kaplan–Meier curves showing the overall survival of patients who received volatile-opioid anesthesia and those who received multimodal anesthesia (MA).

Table 3. Multivariate Cox Proportional Hazard Models for overall survival.

	Unmatched HR (95% CI), p value	After propensity score matching HR (95% CI), p value
Preoperative PLR (every 10 unit increment)	1.04 (1.02, 1.06), <.001	1.05 (1.01, 1.09), .014
Tumor grade	12.44 (5.87, 26.39), <.001	12.42 (4.99, 30.92), <.001
High versus low
Intermediate versus low	4.31 (2.25, 8.24), <.001	4.75 (1.96, 11.53), <.001
Extraabdominal disease: Yes versus no	4.63 (1.71, 12.53), .003	13.41 (3.64, 49.33), <.001
Neoadjuvant chemotherapy: Yes versus no	1.89 (1.04, 3.45), .038	–
Estimated blood loss (every 50 ml increase)	1.03 (1.01, 1.05), .003	–
Anesthetic management: MA versus VO	1.59 (0.89, 2.84), .115	1.66 (0.86, 3.20), .128

CI: confidence interval; HR: hazard ratio; PLR: platelet:lymphocyte ratio; MA: multimodal anesthesia; VO: volatile-opioid anesthesia.