Daily ReportOct 8, 2026
Anesthesiology, October 8 edition
We read 46 papers and selected 3.
Summary
Today’s strongest anesthesiology papers address three high-impact questions: whether age-based routine preoperative echocardiography improves outcomes, whether institution-wide enhanced surgical recovery reduces opioid exposure, and whether total intravenous anesthesia improves survival after esophagogastric cancer surgery. The findings support selective rather than age-only echocardiography, demonstrate large system-level opioid reductions, and suggest—but do not establish—a possible oncologic advantage of total intravenous anesthesia.
Research Themes
- Quasi-experimental evaluation of routine preoperative testing
- System-wide enhanced recovery and opioid-sparing perioperative care
- Long-term oncologic outcomes associated with anesthetic technique
Selected Articles
1. Age-Based Preoperative Transthoracic Echocardiography, Intraoperative Hypotension, and Postoperative Outcomes in Older Adults Undergoing Noncardiac Surgery: A Regression Discontinuity Analysis.
In 7,270 elective noncardiac surgery patients aged 60–89 years, a policy threshold at age 75 increased the probability of preoperative TTE by 43.1 percentage points but did not clearly reduce intraoperative hypotension. Mortality, acute kidney injury, unplanned critical care admission, and hospital stay had imprecise estimates, so clinically meaningful benefit or harm could not be excluded.
Impact: This study uses a quasi-experimental design to address confounding by indication, directly testing whether an age-based testing policy improves perioperative care. Its negative or inconclusive findings challenge age alone as a sufficient justification for routine preoperative echocardiography.
Clinical Implications: Routine preoperative TTE should not be automatically ordered solely because a patient is 75 years or older. Preoperative cardiac imaging should instead be guided by symptoms, functional status, known cardiovascular disease, surgical risk, and established guideline-based indications.
Key Findings
- Among 7,270 patients, the probability of receiving preoperative TTE increased by 43.1 percentage points at the age-75 policy threshold.
- The estimated effect of TTE on intraoperative hypotension was a 24.8-minute reduction, but the 95% confidence interval ranged from a 71.1-minute reduction to a 21.5-minute increase.
- Point estimates for mortality, acute kidney injury, unplanned critical care admission, and hospital stay generally favored TTE but were imprecise and not conclusive.
Methodological Strengths
- The fuzzy regression discontinuity design reduced confounding by indication around the age threshold.
- Sensitivity analyses using alternative bandwidths and covariate adjustment produced similar results, and continuity of baseline characteristics was assessed.
Limitations
- This was a single-center retrospective study, and the local treatment effect near age 75 may not generalize to other institutions or age ranges.
- The study was not powered to exclude clinically meaningful effects on mortality, acute kidney injury, or critical care use.
Future Directions: Future studies should evaluate selective, risk-based echocardiography strategies using multicenter pragmatic designs and should identify patient subgroups in whom preoperative TTE changes anesthetic management or improves outcomes.
BACKGROUND: The clinical value of routine preoperative transthoracic echocardiography (TTE) in older adults remains controversial. Existing evidence is largely observational and vulnerable to confounding by indication, limiting causal interpretation of whether preoperative TTE improves intraoperative management and perioperative outcomes. We aimed to evaluate the local effect of routine age-based preoperative TTE using a quasi-experimental design.
2. Impact of a Multidisciplinary Institution-Wide Enhanced Surgical Recovery Framework on Perioperative Opioid Use: A Retrospective Cohort Study of 49,394 Patients.
In 49,394 patients undergoing ambulatory and inpatient surgery, institution-wide enhanced surgical recovery implementation was associated with lower inpatient and post-discharge opioid exposure across all discharge groups. For patients discharged on postoperative day 2 or later, inpatient opioid use fell from a median of 50.5 to 36.3 oral morphine equivalents per day and outpatient prescribing fell from 300 to 150 oral morphine equivalents, while maximum pain scores remained stable.
Impact: The study provides large-scale real-world evidence that multidisciplinary, institution-wide implementation can reduce opioid exposure without worsening pain. It demonstrates how system-level perioperative practice change, rather than an isolated intervention, can influence outcomes across diverse surgical populations.
Clinical Implications: Hospitals should consider multidisciplinary enhanced surgical recovery pathways incorporating patient education, non-opioid medications, and regional anesthesia. Implementation should remain protocol-informed but adaptable to procedure type, discharge disposition, and patient-specific analgesic needs.
Key Findings
- The cohort included 49,394 patients: 14,607 before enhanced surgical recovery implementation and 34,787 after implementation.
- Among patients discharged on postoperative day 2 or later, inpatient opioid use decreased from 50.5 to 36.3 oral morphine equivalents per day, and total outpatient opioid prescribing decreased from 300 to 150 oral morphine equivalents.
- Multimodal analgesia use increased substantially, while maximum pain scores remained stable across discharge groups.
Methodological Strengths
- The study analyzed nearly 50,000 patients over a 10-year period across ambulatory and inpatient surgical services.
- Segmented regression examined temporal trends and identified opioid reductions beginning during program planning and protocol initiation.
Limitations
- The retrospective before-and-after design cannot fully exclude secular trends, changes in case mix, or other concurrent institutional initiatives.
- Variation in individual enhanced recovery protocols and multimodal analgesia components limits attribution of the observed effect to any single intervention.
Future Directions: Future research should use multicenter implementation studies, interrupted time-series or stepped-wedge designs, and patient-centered outcomes to determine which program components produce the greatest opioid reduction and whether effects persist long term.
BACKGROUND: Enhanced surgical recovery (ESR) programs aim to support opioid-sparing care through patient education and multimodal analgesia (MMA) with pharmacologic and regional anesthesia approaches. Few studies have evaluated longitudinal, institution-wide ESR implementation across multiple surgical specialties. METHODS: We completed a retrospective cohort analysis of patients with eligible surgical procedures 2 years prior to ESR implementation (base) and after implementation (ESR) for ambulatory and inpatient surgeries at a large academic medical center, covering a 10-year span.
3. Survival outcomes following total intravenous versus volatile anesthesia in esophagogastric cancer surgery: a systematic review and meta-analysis.
This review included 13 studies involving 264,543 patients, including 3 randomized trials and 10 retrospective studies. Total intravenous anesthesia was associated with better overall survival than volatile anesthesia overall (hazard ratio 0.80, 95% confidence interval 0.69–0.93), with a stronger association after gastrectomy but not esophagectomy; recurrence-free survival and early mortality differences were not statistically significant.
Impact: The paper addresses a potentially modifiable anesthetic factor with implications for long-term cancer outcomes and synthesizes evidence from more than 264,000 patients. Its value is tempered by the predominance of retrospective studies, making the findings hypothesis-generating rather than practice-changing.
Clinical Implications: Total intravenous anesthesia may be considered a reasonable option for patients undergoing gastrectomy, but current evidence is insufficient to mandate it for oncologic benefit. Anesthetic choice should continue to incorporate patient factors, surgical requirements, recovery goals, adverse-effect profiles, cost, and local expertise until adequately powered prospective randomized trials are available.
Key Findings
- Thirteen studies involving 264,543 patients were included; 41,977 received total intravenous anesthesia and 222,566 received volatile anesthesia.
- Overall survival was better with total intravenous anesthesia in the pooled analysis of eight studies, with a hazard ratio of 0.80 and a 95% confidence interval of 0.69–0.93.
- The survival association was significant after gastrectomy but not esophagectomy; recurrence-free survival, early mortality, operative time, and hospital stay did not differ significantly.
Methodological Strengths
- The review followed PRISMA 2020 principles and used random-effects models to account for between-study variation.
- The analysis included clinically relevant subgrouping by gastrectomy versus esophagectomy and reported hazard ratios with confidence intervals.
Limitations
- Ten of the 13 included studies were retrospective, leaving substantial risk of confounding by indication and treatment selection.
- Methodological heterogeneity and the limited number of randomized trials reduce certainty regarding a causal survival benefit from total intravenous anesthesia.
Future Directions: Large, prospective, multicenter randomized trials should compare standardized total intravenous and volatile anesthesia protocols within specific upper gastrointestinal cancer populations, with long-term overall survival, recurrence, immune markers, and quality of recovery as prespecified outcomes.
PURPOSE: Esophagogastric cancers remain among the leading causes of cancer-related mortality worldwide. Surgical resection represents the primary curative treatment strategy; however, perioperative factors may influence long-term oncological outcomes. Experimental and clinical evidence suggests that anesthetic techniques may affect tumor progression and recurrence through immunological and oncological pathways.