Pain and immune function in patients undergoing gastric cancer surgery following stellate ganglion block with total intravenous anesthesia

Abstract

BACKGROUND

Stellate ganglion block is a commonly used sympathetic nerve block technique that restores the balance of the sympathetic and vagal nervous systems of the body and inhibits sympathetic nerve activity.

AIM

To analyze the effect of a stellate ganglion block combined with total diploma intravenous anesthesia on postoperative pain and immune function in patients undergoing laparoscopic radical gastric cancer (GC) surgery to provide a reference basis for the formulation of anesthesia protocols for radical GC surgery.

METHODS

This study included 112 patients who underwent laparoscopic radical surgery for GC between January 2022 and March 2024. There was no restriction on sex. The patient grouping method used was a digital random table method, and the number of cases in each group was 56. The control group was administered total intravenous anesthesia, and the observation group compounded the stellate ganglion block according to the total intravenous anesthesia protocol. Postoperative hemodynamics, pain levels, and immune indices were compared between the groups.

RESULTS

The heart rate and mean arterial pressure in the observation group after intubation were lower than those in the control group (P < 0.05). Pain levels were compared between the two groups at 2 hours, 12 hours, 24 hours, and 48 hours after surgery (P > 0.05). The number of CD3⁺, CD4⁺, and CD4⁺/CD8⁺ cells at the end of surgery was higher in the observation group than in the control group, and the number of CD8⁺ cells was lower in the observation group than in the control group (P < 0.05). There were no significant differences between the two groups in terms of propofol dosage, awakening time, extubation time, or postoperative adverse reactions (P > 0.05).

CONCLUSION

The application of a stellate ganglion block combined with total intravenous anesthesia had no significant effect on postoperative pain levels in patients undergoing laparoscopic radical GC surgery. However, it can safely reduce the effect of surgery on the immune function of patients and is worth applying in clinical practice.

Key Words: Stellate ganglion block; Total intravenous anesthesia; Laparoscopy; Radical gastric cancer surgery; Immune

Core Tip: In this study, we found that stellate ganglion block combined with general intravenous anesthesia could decrease the need for analgesic drugs and possibly improve immune function in patients undergoing laparoscopic radical surgery for gastric cancer, thus providing novel avenues for optimal surgical anesthesia management.

INTRODUCTION

Gastric cancer (GC) is a common malignant tumor of the gastrointestinal tract. According to relevant surveys[1], the incidence and mortality rates of GC rank third among all cancer types in China, accounting for approximately 44.0% and 48.6% of emerging GC cases and GC-related deaths, respectively, worldwide, which seriously threaten the physical and mental health of residents. Surgery is the most important method for treating GC, among which laparoscopic radical gastrectomy for GC is less traumatic to tissues and faster in recovery, and has been gradually favored by most patients and physicians[2]. However, a series of traumatic operations, such as surgery and anesthesia, induce sympathetic nerve excitation, break the internal stability of the vegetative nervous system in the organism, and lead to immunosuppressive reactions in patients after surgery[3]. Pain is a common subjective experience in surgical patients, mainly due to injurious stimulation caused by surgical and anesthetic operations. Therefore, when performing radical laparoscopic GC surgery, it is particularly important to adopt measures that reduce surgical stress and improve surgical outcomes. The stellate ganglion refers to the sympathetic ganglion of the neck and chest. By anesthetic blockade of this area, sympathetic nerve activity can be suppressed and the endocrine and immune systems of the body and other functions can be regulated[4]. Therefore, the present study considered patients undergoing laparoscopic radical GC surgery as research subjects and combined the stellate ganglion block technique with the same general intravenous anesthesia to provide a reference basis for formulating anesthesia protocols for radical GC surgery.

MATERIALS AND METHODS

General information

A total of 112 patients who underwent laparoscopic radical gastrectomy for GC and were admitted to our hospital between January 2022 and March 2024 were selected and grouped using a digital random table method. The control group comprised 56 patients, 30 males and 26 females; aged 45–75 years (58.93 years ± 6.82 years); body mass index 18–28 kg/m² (22.93 kg/m² ± 2.84 kg/m²); and 34 cases and 22 cases classified as grades II and III, respectively, according to the Association of Anaesthesiologists' (ASA) class. The observation group comprised 56 patients, 28 males and 28 females; aged 45–76 years (60.04 years ± 7.08 years); body mass index 18–28 kg/m² (23.04 kg/m² ± 2.96 kg/m²); and 32 cases and 24 cases classified as grades II and III, respectively, according to ASA classification. The baseline data of the two groups of patients were compared, with statistical significance set at P > 0.05.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Patients who met the diagnostic criteria for GC[5]; (2) Patients who were in the hospital for elective radical GC surgery; (3) ASA anesthesia classification II to III; and (4) Patients who agreed to the specific details of the study and signed an informed consent form.

The exclusion criteria were as follows: (1) Patients with central nervous system diseases and audio-visual disorders; (2) Those with a history of allergy to anesthetic drugs; (3) Those with a history of thoracic and abdominal surgery; (4) Those with immunological diseases or in a state of immunosuppression; (5) Those who had distant metastases of GC for palliative surgery; (6) Those with lesions of important organs, such as the heart, liver, and kidneys; and (7) Those suffering from other.

Methods

Both groups underwent routine fasting before surgery and cardiac monitoring was performed after admission.

In the control group, total intravenous anesthesia was administered during surgery following the regimens: Midazolam at a dose of 0.05 mg/kg, etomidate at a dose of 0.3 mg/kg, cisatracurium at a dose of 0.3 mg/kg, and sufentanil at a dose of 0.3 mg/kg. Sufentanil at a dose of 0.4 µg/kg was injected intravenously; after successful induction, the trachea was intubated and the anesthesia machine was connected. Anesthesia maintenance regimen was as follows: Propofol at a dose of 3–5 mg/kg/hour, remifentanil at a dose of 0.1–0.3 µg/kg/minute, pumped, with cisatracurium injected intermittently during the period.

In the observation group, a stellate ganglion block was added to the total intravenous anesthesia program, which was the same as that of the control group. Before the induction of anesthesia, a puncture was performed at the level of the transverse process of the sixth cervical vertebra on the right side. The patient was placed in a supine position, the right shoulder was padded with a hugging pillow, with the shoulders elevated by 30, and the head tilted to the left. The needle was injected with 0.5% ropivacaine 7 mL under the condition that the tip of the needle arrived at the deep surface of the prevertebral fascia and the cervical longissimus muscle between the fascia and the cervical longissimus muscle, there was no cerebrospinal fluid in the retraction, and there was no resistance to the injection. The drug diffused well on ultrasound, was withdrawn from the needle, and covered with sterile dressings, suggesting Horner's syndrome; that is, the block was successful.

In both groups, additional vasoactive drugs were administered according to the signs during anesthesia maintenance, and the pumped-in volume of the anesthetic was gradually reduced toward the end of the surgery. An intravenous self-control analgesic device was retained in position in the postoperative period, with the following analgesic drugs: Dizocin at a dose of 0.3 mg/mL, tropansetron at a dose of 0.1 mg/mL, and sufentanil at a dose of 0.5 µg/mL. Saline was added to achieve an analgesic dose of 100 mL. The background infusion rate was set to 2 mL/hour, the first infusion dose was 2 mL, the self-control dose was 2 mL each time, and the compression interval was 20 minutes.

Observation indicators

Hemodynamics: The heart rate (HR) and mean arterial pressure (MAP) were monitored before admission (T0), immediately after intubation (T1), at the time of skin cutting (T2), 60 minutes after surgery (T3), and at the end of surgery.

Pain: The pain levels of the two groups at 2 hours, 12 hours, 24 hours, and 48 hours after surgery were recorded, and the numerical rating scale (NRS)[6] was used to evaluate the pain level of the patients at rest, with a score scale of 0–10; the score increased with the aggravation of pain.

Immune function: Venous blood (3 mL) was collected, the collection time points were 1 day before surgery and 6 hours after surgery, and the indices to be examined were CD3⁺, CD4⁺, CD8⁺, and CD4⁺/CD8⁺.

Surgical anesthesia included the propofol dose, awakening time, extubation time, postoperative adverse reactions, local anesthetic poisoning, accidental perforation of blood vessels, pneumothorax, limb numbness, respiratory depression, nausea, and vomiting.

Statistical analysis

Statistical analysis of the data was performed using the Statistical Package for the Social Sciences (version 26.0). Measurement data were described in mean ± SD, and the test was independent samples t when conforming to normal distribution; count data were expressed as rate (%), and χ² test was performed. Statistical significance was set at P < 0.05.

RESULTS

Hemodynamics

At T0, HR and MAP were compared between the two groups (P > 0.05); at T1–T3, HR and MAP increased in both groups but were lower in the observation group than in the control group (P < 0.05) (Table 1).

Table 1 Comparison of heart rate and mean arterial pressure between the two groups at different time points.

Group	Index	Before admission	Immediately after intubation	At the time of skin cutting	The 60 minutes after surgery	At the end of surgery
Observation group	HR (beats/minute)	69.82 ± 8.26	78.28 ± 7.15a,b	79.20 ± 7.24a,b	80.14 ± 7.35a,b	71.28 ± 8.61
	MAP (mmHg)	82.84 ± 6.36	92.18 ± 7.28a,b	93.58 ± 7.52a,b	92.04 ± 6.86a,b	83.10 ± 7.10
Control group	HR (beats/minute)	70.04 ± 8.28	86.86 ± 8.15a	85.82 ± 8.20a	86.20 ± 8.42a	71.08 ± 7.52
	MAP (mmHg)	83.04 ± 6.48	101.28 ± 7.58a	99.82 ± 7.50a	96.82 ± 6.96a	84.01 ± 7.15

^aP < 0.05, compared with admission within the same group.

^bP < 0.05, compared with the control group.

HR: Heart rate; MAP: Mean arterial pressure.

Pain level

The NRS scores at different postoperative time points between the two groups were similar between the two groups (P > 0.05) (Table 2).

Table 2 Comparison of postoperative numerical rating scale scores between the two groups.

Group	The 2 hours after surgery	The 12 hours after surgery	The 24 hours after surgery	The 48 hours after surgery
Observation group	2.48 ± 0.82	3.18 ± 1.04	2.82 ± 1.01	2.08 ± 0.68
Control group	2.53 ± 0.85	3.24 ± 1.05	2.90 ± 1.02	2.13 ± 0.71
t value	0.317	0.304	0.417	0.381
P value	0.752	0.762	0.677	0.704

Immune function

The immune indices of the two groups were compared 1 day before surgery (P > 0.05). At the end of surgery, the immune indices of the control group were significantly changed compared to the preoperative period (P < 0.05). However, the immune indices in the observation group were not significantly different before and after surgery (P > 0.05). In contrast, the immune indices of the observation group were significantly different from those of the control group (P < 0.05; Table 3).

Table 3 Comparison of immunological indices between the two groups.

Group	CD3+		CD4+		CD8+		CD4+/CD8+
	The 1 day before surgery	After surgery	The 1 day before surgery	After surgery	The 1 day before surgery	After surgery	The 1 day before surgery	After surgery
Observation group	52.43 ± 4.18	51.80 ± 4.20	36.10 ± 6.25	35.92 ± 6.20	24.10 ± 2.18	24.84 ± 2.36	1.50 ± 0.28	1.48 ± 0.26
Control group	51.80 ± 4.20	46.02 ± 3.96a	35.89 ± 6.36	30.13 ± 6.18a	23.86 ± 2.20	27.86 ± 2.41a	1.51 ± 0.30	1.08 ± 0.21a
t value	0.796	7.493	0.176	4.950	0.580	6.700	0.182	8.956
P value	0.428	< 0.001	0.860	< 0.001	0.563	< 0.001	0.856	< 0.001

^aP < 0.001, indicate significant differences between the two groups at the corresponding time point.

Anesthesia

The observation group did not experience local anesthetic poisoning, mispenetration of blood vessels, pneumothorax, limb numbness, or respiratory depression. In contrast, one case of nausea and vomiting (1.79%), two cases of nausea and vomiting, and one case of respiratory depression were reported in the control group, with an incidence rate of 5.36%. However, the comparison of complications and specific anesthesia indices between the two groups did not reveal significant differences (P > 0.05), as shown in Table 4.

Table 4 Comparison of anesthetic conditions between the two groups.

Group	Propofol dosage (mg)	Recovery time (minute)	Extubation time (minute)
Observation group	958.83 ± 25.82	18.04 ± 4.28	22.48 ± 3.36
Control group	961.20 ± 27.30	17.89 ± 4.36	23.04 ± 3.48
t value	0.472	0.184	0.866
P value	0.638	0.855	0.388

DISCUSSION

Laparoscopic radical gastrectomy for GC is an effective method for treating GC. Although laparoscopic surgery can reduce surgical trauma, it remains a stressful procedure that prompts the body to produce excessive stress reactions. Simultaneously, the operation time is long, and the patients' tolerance to a series of invasive operations, such as anesthesia drugs, tracheal intubation, and other invasive operations, gradually decreases, which further affects patient recovery. Therefore, reducing surgical stress reactions in patients and promoting better recovery has become the focus of clinical research. Total intravenous anesthesia is a common anesthetic method used during surgery. Although it can inhibit sympathetic responses, it cannot completely inhibit the intraoperative stress responses. In particular, after general anesthesia, the patient is in a hypercoagulable state, at which time the intraoperative hemodynamic fluctuation is abnormal, and the stress response is notable. Abundant nerve blocks and vascular branches were observed around the stellate ganglion. Anesthetic blockade of this area can affect the autonomic, cardiovascular, endocrine, and immune systems of an organism, thus exerting a significant anesthetic blockade effect[7]. This study showed that the HR and MAP of both groups of patients after intubation under anesthesia were significantly elevated; however, the magnitude of elevation in the observation group was lower than that in the control group (P < 0.05). This indicates that the combined stellate ganglion block technique can maintain relatively smooth intraoperative hemodynamics in patients. Yan et al[8] demonstrated that combined stellate ganglion blockade in patients undergoing radical surgery for malignant gastrointestinal tumors maintained HR and MAP, and stabilized perioperative hemodynamics after tracheal intubation and at the end of surgery. Using a stellate ganglion block before the induction of anesthesia in patients, ropivacaine injected into the loose connective tissue containing the stellate ganglion can block sympathetic nerve activity and maintain the stability of the sympathetic and vagal nervous systems, which in turn can maintain relatively stable hemodynamics[9]. Meanwhile, the stellate ganglion block can expand the patient's cerebral blood vessels, facilitate cerebral blood circulation, increase hypothalamic blood flow, and provide sufficient oxygen exchange to the hypothalamus, which can regulate the vegetative nervous system and improve the body's ability to cope with the stress of surgery and anesthesia[10]. In addition, the injurious stimuli produced by surgery and anesthesia on the body will enhance sympathetic activity and increase sympathetic nervous tension, whereas stellate ganglion blockade reduces sympathetic tone and the effects of injurious stimuli on the nervous system, thereby reducing perioperative hemodynamic fluctuations[11].

Postoperative pain is a common manifestation that affects the postoperative rehabilitation of patients due to trauma caused by laparoscopic radical GC surgery. The present study showed no significant differences in pain levels between the two groups at 2 hours, 12 hours, 24 hours, and 48 hours after surgery (P > 0.05). The stellate ganglion block was found to have little effect on the patients, which may be because they were retained in postoperative self-controlled analgesic intravenous pumps, which can have a corresponding analgesic effect. In addition, patients were anesthetized before the stellate ganglion block. Ropivacaine, a local anesthetic drug, has certain sedative and analgesic effects, and its half-life ranges from 4 hours to 14 hours. From the end of the surgery to the postoperative period of 2 hours, the drug is gradually metabolized, and its efficacy slowly decreases. At this time, the analgesic effect of anesthesia was not significant; therefore, the analgesic scores of the two groups of patients were not significantly different. In addition, the results showed that there were no differences in the propofol dose, awakening time, extubation time, or postoperative adverse reactions between the two groups (P > 0.05). This indicates that the use of a stellate ganglion block does not affect the patients' post-anesthesia awakening effect, and its safety is high, making it worthy of clinical application.

The obvious stress reaction caused by surgery and anesthesia prompts the release of catecholamines into the patient's body, which in turn suppresses the postoperative cellular immune function[12]. Simultaneously, postoperative epinephrine and norepinephrine are released by binding to the β-adrenergic receptors on the surface of the immune cells, thereby generating immunosuppression, leading to a strong stress reaction[13]. Immunosuppression, in turn, affects the suppression of tumor cells, leading to their escape of tumor cells from immune surveillance, thus contributing to the growth and recurrence of tumor cells. This study showed that the CD3⁺, CD4⁺, and CD4⁺/CD8⁺ cell counts at the end of surgery in the observation group were higher than those in the control group and that the CD8⁺ cell counts were lower than those in the control group (P < 0.05). A stellate ganglion block composite total diploma under intravenous anesthesia can reduce surgical stress reactions and indirectly regulate the immune system. Li et al[14] pointed out that the stellate ganglion block can inhibit the autophagic function of lymphocytes and promote the proliferation of CD4⁺ T cells, which improves the immune function of patients. Gu et al[15] reported that a stellate ganglion block could reduce the perioperative levels of norepinephrine and cortisol and play an anti-stress role in older adult patients undergoing thoracoscopy for lung cancer. Therefore, the stellate ganglion block technique can stabilize the autonomic nervous system, inhibit the release of stress factors such as norepinephrine and cortisol, stabilize the internal environment of the organism, reduce the state of immunosuppression caused by the stress reaction, and protect the immune function of patients. At the same time, stellate ganglion block can increase local oxygen content, promote the elimination of oxidative stress products in the body, and reduce the expression of immune complexes, thus improving immune function.

In conclusion, the application of stellate ganglion block combined with a total diploma of intravenous anesthesia can reduce the degree of postoperative pain in patients undergoing laparoscopic radical surgery for GC, with a lower impact on postoperative immune function and higher safety, which is worthy of clinical application.

CONCLUSION

Patients undergoing radical laparoscopic GC surgery are susceptible to immunosuppression and hemodynamic instability owing to the stimulation of surgery, anesthesia, and other operations, and the use of a composite stellate ganglion block during general intravenous anesthesia can inhibit the surgical stress response, maintain the patient’s perioperative hemodynamics in a relatively stable manner, alleviate the state of immunosuppression in the postoperative period, and have no abnormal effects on the patient’s postoperative anesthesia awakening, which is worth applying in clinical practice.