Effects Of Combined General Anesthesia And Thoracic Epidural Anesthesia On Postoperative Pulmonary Complications In Elderly Patients Undergoing Laparoscopic Gastrectomy

Objective:General anesthesia combined with epidural anesthesia?GEA?is an important part of the ERAS.Compared with general anesthesia?GA?,the application of GEA in open gastrointestinal surgery can reduce postoperative pulmonary complications?PPCs?.However,there are few studies on the application of GEA in laparoscopic gastrectomy in elderly patients.The purpose of our study was to investigate the effect of GEA on postoperative pulmonary complications in elderly patients undergoing laparoscopic radical gastrectomy.Methods:Our study is a prospective randomized controlled clinical trial,82patients aged between 70-80 undergoing laparoscopic radical gastrectomy were randomly divided into GEA group and GA group.The perioperative preparation and management of the two groups were carried out according to the concept of ERAS.Laparoscopic gastrectomy and the lymph node dissection according to the D2 standard lymph node dissection in Japanese gastric cancer treatment guidelines?4th edition?were performed in both groups.Gastrointestinal tract reconstruction was performed by Roux-en-Y anastomosis.In GEA group,general anesthesia combined with epidural anesthesia was used.Ropivacaine was used to discontinue local anesthesia through epidural catheter.After confirming the correct position of the catheter,appropriate amount of general anesthesia was given to maintain the depth of anesthesia during operation.Patient-controlled epidural analgesia?PCEA?was used in GEA group postoperatively.In GA group,general anesthesia was used,and patient-controlled intravenous analgesia?PCIA?was used after operation.The primary outcome was the incidence of PPCs in the two groups,including pneumonia,atelectasis,respiratory failure,pleural effusion.The secondary outcome included clinical pneumonia severity score?CPIS?,arterial partial pressure of oxygen?Pa O₂?and oxygenation index?OI?,postoperative pain visual analogue?VAS?score,operation time,mechanical ventilation time,total usage of anesthetic drugs,ICU hospitalization days,postoperative flatus time,postoperative hospitalization days and so on.Postoperative complications were recorded and compared according to Clavien-Dindo complication grading system.The levels of white blood cell count?WBC?,interleukin-1?IL-1?,interleukin-6?IL-6?,C-reactive protein?CRP?,tumor necrosis factor-??TNF-??,norepinephrine?NE?and cortisol?Cor?were collected and analyzed before operation and on POD1,POD3 and POD5.Results:A total of 82 patients were included in the final analysis,including 40patients in GEA group and 42 patients in GA group.Compared with GA group,the total incidence of postoperative pulmonary complications in GEA group was lower than that in GA group,and there was significant difference between the two groups.The CPIS score in GEA group was lower than that in GA group?P<0.05?.Pa O₂ and OI in GEA group were higher than those in GA group?P<0.05?.The dosage of sufentanil in GEA group was lower than that in GA group,and there was significant difference between the two groups?P<0.001?.The first exhaust time in GEA group was shorter than that in GA group,and there was significant difference between the two groups?P<0.05?.The resting VAS score on the POD1and POD2 in the GEA group was lower,and there was significant difference between the two groups.The exercise VAS score on the POD1,POD2 and POD3was lower in the GEA group,and there was significant difference between the two groups?P<0.05?.The levels of WBC,IL-1,IL-6,NE and Cor in GEA group were significantly lower than those in GA group on the POD1.The level of IL-1in GEA group was significantly lower than that in GA group on the POD3.There was no difference in the Clavien-Dindo grade of postoperative complications between GEA group and GA group,and there was no statistical significance between the two groups?P>0.05?.Conclusion:The results of this study show that compared with GA only,GEA can significantly reduce the incidence of PPCs in elderly patients with gastric cancer.the incidence of postoperative pneumonia and atelectasis decreased significantly.GEA can shorten the recovery time of gastrointestinal function and has better postoperative analgesic effect.GEA does not increase the incidence of general complications in elderly patients with gastric cancer.Therefore,it is safe and effective for elderly patients undergoing laparoscopic gastrectomy under general anesthesia combined with epidural anesthesia.