Comparison of recovery effect for sufentanil and remifentanil anesthesia with TCI in laparoscopic radical resection during colorectal cancer
- Authors:
- Published online on: March 31, 2016 https://doi.org/10.3892/ol.2016.4394
- Pages: 3361-3365
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Copyright: © Qi et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
Abstract
Introduction
Colorectal cancer is one of the most common types of digestive tract tumors affecting 1.23 million individuals per year (9.7% of overall cancers) and is the fourth most common cause of mortality from cancer worldwide (608,000 cases, 8% of overall cancer deaths) (1). Currently, laparoscopic radical resection is the most widely used clinical treatment for colorectal cancer, however, it causes great discomfort for the patient (2). To improve the quality of anesthesia in the laparoscopic radical resection of colorectal cancer is a challenge for the medical field (3,4). Target-controlled infusion (TCI) is a new approach of anesthesia. TCI has the advantages of rapid drug delivery and simple operation (5). It has greatly improved the controllability and safety of clinical anesthesia, and has attracted increasing attention.
Sufentanil and remifentanil are opioid receptor agonists with a great analgesic effect during surgery (6–11). However, there are few comparative studies available on the application of the two agonists in the laparoscopic radical resection of colorectal cancer with TCI. The aim of the present study was to sufentanil and remifentanil anesthesia with TCI in the laparoscopic radical resection of colorectal cancer, and examine their impact on patient stress response and cellular immunity to provide a theoretical reference for clinical anesthesia.
Patients and methods
General information
A total of 192 elderly patients were selected to perform laparoscopic radical resection of colorectal cancer between July 2014 and October 2015. The patients included 106 males and 86 females, aged 62–81 years, with an average age of 74.3±3.1 years, and a weight of 54–82 kg, with an average weight of 67.6±2.5 kg. The selected cases were confirmed as colorectal cancer following colonoscopy and pathological examination. Patients who had previously used opioid drugs or had an allergy to sufentanil and remifentanil, or had serious damage of the heart, lung, liver, kidney function or other malignant tumor were excluded. The patients were divided randomly into the sufentanil and remifentanil groups (n=96 per group). The differences between the two groups with regard to gender, age and weight were not statistically significant (P>0.05), which was comparable.
Method
Prior to surgery, electrocardiogram and monitoring of vital signs were implemented in the two groups of patients, and an intramuscular injection of atropine (0.5 mg) and sodium phenobarbital (0.1 g) was performed. After 3 min of breathing with oxygen mask, rapid establishment of venous access and anesthesia induction was performed.
The sufentanil group used TCI sufentanil anesthesia (Langfang branch of Sinopharm Chemical Reagent Co., Ltd.; national medicine permission no. H20123298; Shanghai, China) at a concentration of 0.4 µg/l. Propofol was produced by Xi'an Libang Pharmaceutical Co., Ltd. (national medicine permission no. H20123318; Xi'an, China) at a concentration of 4 mg/l. Mechanical ventilation was carried out when plasma concentration of patients was in a state of equilibrium. During surgery, the concentration of propofol was controlled at 4 mg/l and rocuronium bromide, produced by Zhejiang Xianju Pharmaceutical Co., Ltd. (national medicine permission no. H20123188; Hangzhou, China), was injected continuously. The injection of sufentanil was ceased at the end of surgery.
The remifentanil group used TCI remifentanil anesthesia (Yichang Humanwell Pharmaceutical Co., Ltd.; national medicine permission no. H20030197; Yichang, China), at a concentration of 4.0 µg/l. The specific surgical process was the same as that of the sufentanil group. The injection of remifentanil was ceased at the end surgery. Temperature-holding nursing was implemented for the two groups. After patients regained their respiratory function and consciousness, catheters were removed and patients were sent to the recovery room.
Observation index
Observation indices were recorded for wake-up time, extubation time, orientation recovery time and adverse reactions, as well as vital signs [heart rate (HR), mean arterial pressure (MAP), arterial oxygen saturation (SpO2)] prior to (T0) and after (T1) anesthesia, at the end of surgery (T2) and 24 h after surgery (T3), 72 h after surgery (T4). The distribution of the stress response index [cortisol (COR), interleukin (IL)-6 and IL-10, glucose (GLU)] and T-lymphocyte subsets (CD3, CD4, CD8 and CD4/CD8).
Statistical analysis
SPSS 21.0 software (IBM SPSS, Armonk, NY, USA) was used for data analysis. Measurement data were presented as mean ± standard deviation and differences between the two groups were determined by the t-test. Enumeration data were presented as a percentage and comparisons between groups were made using the χ2 test. P<0.05 was considered to indicate statistically significant results.
Results
Comparison of the quality of anesthesia recovery in the two groups
The wake-up and extubation times of the remifentanil group were significantly lower than those in the sufentanil group (P<0.01), and the difference of orientation recovery time in the two groups was not statistically significant (P>0.05; Table I).
Comparison of the changes of vital signs in the two groups
The differences of vital signs (HR, MAP, SpO2) after the anesthesia (T1) and at the end of surgery (T2) were not statistically significant (P>0.05). However, the remifentanil group had obvious changes after anesthesia (T1) and at the end of surgery (T2) in that HR improved, whereas MAP and SpO2 significantly decreased (P<0.05; Table II).
Comparison of stress response indices in the two groups
The concentration of GLU, COR, IL-6 and C-reactive protein (CRP) of patients in the sufentanil group maintained stability, while the indices in the remifentanil group exhibited an increasing trend during the process of anesthesia and surgery, with a longer recovery following surgery. The differences of indices of GLU, COR, IL-6 and CRP between the two groups in T0 were not statistically significant (P>0.05). However, statistical significance was observed for (P<0.05) in T1, T2, T3, T4 (Table III).
Distribution of T-cell subsets in the two groups
The degree of reduction of T-lymphocyte subsets in the sufentanil group was lower than that in the remifentanil group, with the sufentanil group having a shorter recovery of cell immune function. The differences of indices of CD3, CD4, CD8, and CD4/CD8 between the two groups in T0 were not statistically significant (P>0.05), whereas, there was statistical significance (P<0.05) for T1, T2, T3, T4 (Table IV).
Comparison of adverse reactions in the two groups
Adverse reactions rate in the sufentanil group during the wake-up process was significantly lower than that in the remifentanil group (P<0.05; Table V).
Discussion
Sufentanil is a type of narcotic drug and opioid receptor agonist, and contains citrate as the main pharmacological component (2–4). Sufentanil is easily transferred through the blood-brain barrier with its high lipid solubility, and can bind with plasma protein for a good analgesic effect, with a longer interval for anesthesia (12,13). Refentanil as an opioid agonist is easily hydrolyzed in human tissues and blood, which has characteristics of rapid onset, short duration of anesthesia and no accumulation inside the human body (14).
The findings of the present study have shown that the wake-up and extubation times of the remifentanil group were significantly longer than those in the sufentanil group (P<0.01). The difference in orientation recovery time between two groups had no statistical significance (P>0.05). Sufentanil injection can be ceased at the end of surgery for its brief duration in the body and short biological half-life, which is controllable in the clinic.
Change of vital signs is an important indicator of surgical anesthesia. The present findings showed that the differences of HR, MAP, SpO2 in T1 and T2 were not statistically significant in the sufentanil group compared with those prior to surgery (P>0.05). However, in the remifentanil group those parameters have obviously altered following surgery. HR increased significantly while MAP and SpO2 decreased significantly in T1 and T2 compared with those prior to surgery (P<0.05). Therefore, sufentanil-based anesthesia with TCI maintains perioperative vital signs in a stable condition and hardly affected patient respiratory function and hemodynamics indices.
Radical resection for colorectal cancer leads to stress response in patients (15,16). Stress response is a non-specific defense reaction that occurs in the human body when externally stimulated. Previous findings (2,17,18) have shown that, stress responses initiated from anesthesia and surgery occur during the perioperative period, with a certain impact on recovery of patients following surgery. Serum COR and blood GLU can reflect t the intensity of stress response in the human body and IL-6 and IL-10 are important cytokines that are involved in the inflammatory response and injury repair and reflect the degree of human stress (19).
In the present study, the concentration of GLU, COR, IL-6 and CRP of patients in the sufentanil group maintained stability, whereas this concentration was increased during anesthesia and surgery in the remifentanil group, and the latter group had a longer recovery period following surgery. The differences of indices of GLU, COR, IL-6, and CRP for the two groups in T0 were not statistically significant (P>0.05), but there was significance for T1, T2, T3 and T4 (P<0.05). This result suggested that sufentanil is able to maintain the blood GLU and COR in a stable condition and has much less stress response than remifentanil.
T lymphocytes and their subsets are the main immune active cells in the body's anti-tumor immunity, of which CD3 can effectively recognize the role of antigen, and is expressed on the surface of mature T lymphocytes. CD4 assists human B-cells to further differentiate and produce antibodies, while CD8 inhibits T-cell proliferation. CD4 and CD8 are expressed on the surface of suppressor cells and cytotoxic T lymphocytes (20–22). The degree of immune function disorder is defined by the ratio CD4/CD8. In the present study, the degree of reduction of T-lymphocyte subsets in the sufentanil group was significantly lower than that in the remifentanil group, with a rapid recovery of cellular immune function. The differences of indices of CD3, CD4, CD8, and the CD4/CD8 ratio in T0 exhibited no statistical significance (P>0.05), whereas statistical significance was identified for T1, T2, T3, T4 (P<0.05). Thus, TCI of sufentanil anesthesia for laparoscopic radical resection for colorectal cancer effectively inhibits the cellular immune function, which recovers in a short time after surgery.
The present study analyzed adverse reactions in the process of wake-up and recovery. The results have shown that the incidence of adverse reactions, which include coughing and dysphoria, in the sufentanil group was significantly lower than that in the remifentanil group (P<0.05). Therefore, the TCI of sufentanil anesthesia is safe and reliable with few side effects. Thus, TCI of sufentanil anesthesia maintains stable hemodynamic and respiratory function and causes less stress response, less inhibition of cellular immunity and fewer side effects in its application. It thus has the potential to become the first choice of anesthesic to be used in the clinic for elderly patients who undergo laparoscopic radical resection for colorectal cancer and therefore may be promoted in the clinic.
References
Dolatkhah R, Somi MH, Bonyadi MJ, Asvadi KI, Farassati F and Dastgiri S: Colorectal cancer in Iran: Molecular epidemiology and screening strategies. J Cancer Epidemiol. 2015:6430202015. View Article : Google Scholar : PubMed/NCBI | |
Hu LG, Pan JH, Li J, Kang F and Jiang L: Effects of different doses of sufentanil and remifentanil combined with propofol in target-controlled infusion on stress reaction in elderly patients. Exp Ther Med. 5:807–812. 2013.PubMed/NCBI | |
Yeganeh N, Roshani B, Latifi H and Almasi A: Comparison of target-controlled infusion of sufentanil and remifentanil in blunting hemodynamic response to tracheal intubation. J Inj Violence Res. 5:101–107. 2013. View Article : Google Scholar : PubMed/NCBI | |
Lilot M, Meuret P, Bouvet L, Caruso L, Dabouz R, Deléat-Besson R, Rousselet B, Thouverez B, Zadam A, Allaouchiche B, et al: Hypobaric spinal anesthesia with ropivacaine plus sufentanil for traumatic femoral neck surgery in the elderly: A dose-response study. Anesth Analg. 117:259–264. 2013. View Article : Google Scholar : PubMed/NCBI | |
Liu S, Wang B, Li S, Zhou Y, An L, Wang Y, Lv H, Zhang G, Fang F, Liu Z, et al: Immune cell populations decrease during craniotomy under general anesthesia. Anesth Analg. 113:572–577. 2011.PubMed/NCBI | |
Heyse B, Proost JH, Schumacher PM, Bouillon TW, Vereecke HE, Eleveld DJ, Luginbühl M and Struys MM: Sevoflurane remifentanil interaction: Comparison of different response surface models. Anesthesiology. 116:311–323. 2012. View Article : Google Scholar : PubMed/NCBI | |
Ogino S, Galon J, Fuchs CS and Dranoff G: Cancer immunology - analysis of host and tumor factors for personalized medicine. Nat Rev Clin Oncol. 8:711–719. 2011. View Article : Google Scholar : PubMed/NCBI | |
Uusitalo-Seppälä R, Koskinen P, Leino A, Peuravuori H, Vahlberg T and Rintala EM: Early detection of severe sepsis in the emergency room: Diagnostic value of plasma C-reactive protein, procalcitonin, and interleukin-6. Scand J Infect Dis. 43:883–890. 2011. View Article : Google Scholar : PubMed/NCBI | |
Kim JH, Byun H and Kim JH: Abuse potential of propofol used for sedation in gastric endoscopy and its correlation with subject characteristics. Korean J Anesthesiol. 65:403–409. 2013. View Article : Google Scholar : PubMed/NCBI | |
Cheung TT and Poon RT: Synchronous resections of primary colorectal tumor and liver metastasis by laparoscopic approach. World J Hepatol. 5:298–301. 2013.PubMed/NCBI | |
Bismuth J and Duran C: Bypass surgery in limb salvage: Inflow procedures. Methodist DeBakey Cardiovasc J. 9:66–68. 2013. View Article : Google Scholar : PubMed/NCBI | |
Fechner J, Ihmsen H, Schüttler J and Jeleazcov C: The impact of intra-operative sufentanil dosing on post-operative pain, hyperalgesia and morphine consumption after cardiac surgery. Eur J Pain. 17:562–570. 2013. View Article : Google Scholar : PubMed/NCBI | |
Li X, Zhang Y, Zhou M, Xia Q, Li W and Lu Q: The effect of small dose sufentanil on emergence agitation in preschool children following sevoflurane anesthesia for elective repair of unilateral inguinal hernia. Saudi Med J. 34:40–45. 2013.PubMed/NCBI | |
Jeleazcov C, Saari TI, Ihmsen H, Schüttler J and Fechner J: Changes in total and unbound concentrations of sufentanil during target controlled infusion for cardiac surgery with cardiopulmonary bypass. Br J Anaesth. 109:698–706. 2012. View Article : Google Scholar : PubMed/NCBI | |
Bidgoli J, Delesalle S, De Hert SG, Reiles E and Van der Linden PJ: A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient. Eur J Anaesthesiol. 28:120–124. 2011. View Article : Google Scholar : PubMed/NCBI | |
Lee JY, Lim BG, Park HY and Kim NS: Sufentanil infusion before extubation suppresses coughing on emergence without delaying extubation time and reduces postoperative analgesic requirement without increasing nausea and vomiting after desflurane anesthesia. Korean J Anesthesiol. 62:512–517. 2012. View Article : Google Scholar : PubMed/NCBI | |
Cabañero D and Puig MM: Immediate and delayed remifentanil-induced hypersensitivity. Anesth Analg. 115:977–978; author reply 978–979. 2012. View Article : Google Scholar | |
Lee C, Kim YD and Kim JN: Antihyperalgesic effects of dexmedetomidine on high-dose remifentanil-induced hyperalgesia. Korean J Anesthesiol. 64:301–307. 2013. View Article : Google Scholar : PubMed/NCBI | |
Gonzalez-Bono E, Rohleder N, Hellhammer DH, Salvador A and Kirschbaum C: Glucose but not protein or fat load amplifies the cortisol response to psychosocial stress. Horm Behav. 41:328–333. 2002. View Article : Google Scholar : PubMed/NCBI | |
Yalcin N, Uzun ST, Reisli R, Borazan H and Otelcioglu S: A comparison of ketamine and paracetamol for preventing remifentanil induced hyperalgesia in patients undergoing total abdominal hysterectomy. Int J Med Sci. 9:327–333. 2012. View Article : Google Scholar : PubMed/NCBI | |
Tiefenthaler W, Pehboeck D, Hammerle E, Kavakebi P and Benzer A: Lung function after total intravenous anaesthesia or balanced anaesthesia with sevoflurane. Br J Anaesth. 106:272–276. 2011. View Article : Google Scholar : PubMed/NCBI | |
Bi SS, Deng CH, Zhou TY, Guan Z, Li L, Li HQ, Zhang LP, Yang L and Lu W: Remifentanil-sevoflurane interaction models of circulatory response to laryngoscopy and circulatory depression. Br J Anaesth. 110:729–740. 2013. View Article : Google Scholar : PubMed/NCBI |