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Sunday, November 23, 2014
Anesthesia and the Immune System Surgery
This is an urgent question as I plan to have a mastectomy in a few days. Does a mastectomy require local, regional or general anesthesia? Does general anesthesia decrease the immune system during the surgery? Is there a way to decrease immunosupression caused by the anesthesia during and after surgery? (i.e. type of anesthesia, adding other fluids, etc...) Thank you for your help.
Thanks for your very interesting questions.
Please keep in mind that this is not an emergency service, and your questions should be discussed with your medical team as soon as possible, preferably well before your operation.
A mastectomy is major surgery and almost always requires general anesthesia. Having said this, I will tell you that modern ideas about optimal anesthesia and pain management have led to the common practice of supplementing general anesthesia with local anesthesia or different regional anesthesia techniques. The regional anesthetic can be something as simple as injecting local anesthetic into the surgical incision site before, during, or after completion of the surgical procedure, or can be as complex as combining epidural or different nerve plexus blocks with the general anesthetic. The exact approach, its benefits, and risks, depend very strongly on the type of surgical procedure, as well as patient factors, and the expertise of the doctors. They are the ones in the best position to decide on the particular anesthetic you receive.
In the case of a mastectomy, one option that has been described, but is probably not very commonly used, is “paravertebral” block, in which multiple injections are made in the back to block some of the intercostals nerves and related nerve fibers. This can decrease the amount of general anesthesia necessary as well as provide good pain relieve for several hours after the operation. Like any medical procedure of course it is not without its own risks (discuss with your doctors).
On the second issue, there is certainly laboratory evidence that many anesthetic agents can decrease the function of some immune cells. Whether this effect translates into any difference in survival or cure rates of cancer is a totally different question. As far as I know, there is no proven effect of this nature and no particular general anesthetic shown to be better than others in this respect. And, after all, there are very few people willing to undergo the experiment of having surgery without anesthesia today! Although immune effects are present, presumably of only a temporary nature, anesthetics also suppress, to a greater or lesser degree, the body’s “stress response” to major surgery. In this case, suppressing the body’s response is thought to be beneficial, and may hasten recovery from surgery and restoration of function.
What is not often realized by our patients is that anesthesia is a far more complicated undertaking than just injecting or breathing a few drugs and then waiting for the patient to ‘wake up”. It includes attention to many of the issues I’ve already mentioned, as well as things you’ve suggested, like administering the appropriate type and quantity of fluid, maintaining heart, kidney and lung function, protecting the body from its own responses to the surgical “injury”, preventing infection, excessive bleeding or blood clots, and providing or initiating adequate pain relief after the operation.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University