TIVA versus volatile anaesthesia in oesophagogastric cancer surgery: a survival association from mostly retrospective data

Design

Systematic review and random-effects meta-analysis, 3 randomised and 10 retrospective studies

Population

264,543 adults having curative surgery for oesophageal or gastric cancer

Primary outcome

Overall survival

Effect

HR 0.80 (95% CI 0.69 to 0.93) favouring TIVA; gastrectomy HR 0.74 (0.60 to 0.91); oesophagectomy HR 0.89 (0.73 to 1.10)

A meta-analysis of 13 studies, three randomised and ten retrospective, covered 264,543 patients, of whom 41,977 received total intravenous anaesthesia and 222,566 volatile anaesthesia. Pooling eight studies, overall survival was better with total intravenous anaesthesia (HR 0.80, 95% CI 0.69 to 0.93).

The association was clear after gastrectomy (HR 0.74, 0.60 to 0.91) and not after oesophagectomy (0.89, 0.73 to 1.10). Recurrence-free survival (0.91, 0.77 to 1.06) and early mortality (0.90, 0.77 to 1.05) were not significantly different. Operation time and hospital stay were similar.

Because most of the data are retrospective, anaesthetic choice may track with hospital, era or patient selection. The authors call for prospective randomised studies. This is a hypothesis, and it should not decide anaesthetic technique by itself.

• Overall survival favoured total intravenous anaesthesia in the pooled analysis (HR 0.80).
• The signal was present after gastrectomy but not oesophagectomy.
• Recurrence-free survival did not differ significantly.
• Most evidence was retrospective, so confounding is likely.
• Discuss the question with your anaesthetist rather than specifying a technique on this evidence.

Why it matters

It tests whether the anaesthetic choice might change cancer outcomes, a question randomised trials have not yet settled.

Don't overread it

Ten of the thirteen studies were retrospective, so the survival difference may reflect confounding rather than the anaesthetic.

The statistics, in plain English

A hazard ratio of 0.80 means 20% fewer deaths at any point in follow-up in the TIVA group in the pooled analysis. In observational data that may reflect who received which anaesthetic. The non-significant recurrence result sits uneasily with an anti-cancer mechanism.

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