{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T00:24:15Z","timestamp":1759969455527,"version":"build-2065373602"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,10,8]],"date-time":"2025-10-08T00:00:00Z","timestamp":1759881600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>There is some evidence to suggest that general anesthesia may influence oncological outcomes, such as survival and disease-free recurrence, in addition to surgical outcomes. This study compares the clinico-oncological outcomes of pancreatic cancer patients who had a pyloric-preserving pancreaticoduodenectomy (PPPD) under epidural anesthesia without endotracheal intubation (EA) and those who received general anesthesia (GA).<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A retrospective cohort investigation comparing pancreatic cancer patients with PPPD under GA and EA. The procedure's feasibility and 30-day clinico-pathological outcomes were evaluated between groups.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The ratio of males to females was 16:5. The mean age was 51 years (range 27\u201374 years). The median hospital stay was 12 days (range 7\u201360). In the GA group, thirteen patients had PPPD and one patient received total pancreatectomy with splenectomy (TPS). On the other hand, in the EA group, six patients received PPPD and two patients underwent TPS. The two groups had similar preoperative demographics, including ASA classification. Seven EA patients underwent successful surgery without GA conversion. Due to respiratory acidosis, one TPS patient was converted to GA before abdominal closure. Neither group had mortality or major cardio-pulmonary issues, with the exception of one case in the GA group who acquired COVID-19 while hospitalized and was ventilated for 10 days until completely recovering. Surgical complications occurred as follows: Two GA patients had pancreatic fistula type B, and one EA patient had a biliary leak, both treated conservatively. One GA patient needed a revision laparoscopy after an iatrogenic bowl perforation during IR drain insertion for chylous ascites on postoperative day 30. All cases had an R0 resection. The histological tumor stage was similar in both groups. The EA group had significantly more harvested lymph nodes and a higher number of lymph node metastases (<jats:italic>p<\/jats:italic>\u2009=\u20090.022 and <jats:italic>P<\/jats:italic>\u2009=\u20090.005, respectively).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Pancreaticoduodenectomy with just epidural anesthesia and without endotracheal intubation can be performed safely in selected cases. It may decrease surgical complications without affecting oncological outcomes. Additional research is necessary to comprehend its actual advantages.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fsurg.2025.1675019","type":"journal-article","created":{"date-parts":[[2025,10,8]],"date-time":"2025-10-08T05:38:48Z","timestamp":1759901928000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Awake pancreaticoduodenectomy without intubation: exploring short-term clinicopathological outcomes of epidural vs. general anesthesia"],"prefix":"10.3389","volume":"12","author":[{"given":"Iyad","family":"Hassan","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lina","family":"Hassan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ibrahim","family":"Gamal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamad","family":"Ibrahim","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wiam","family":"Hassan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,10,8]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1605","DOI":"10.1056\/NEJMra0901557","article-title":"Pancreatic cancer","volume":"362","author":"Hidalgo","year":"2010","journal-title":"N Engl J Med"},{"key":"B2","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1097\/ALN.0000000000002506","article-title":"Anesthesia and cancer recurrence: context for divergent study outcomes","volume":"130","author":"Sessler","year":"2019","journal-title":"Anesthesiology"},{"key":"B3","doi-asserted-by":"publisher","first-page":"660","DOI":"10.1097\/00000542-200610000-00008","article-title":"Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis?","volume":"105","author":"Exadaktylos","year":"2006","journal-title":"Anesthesiology"},{"key":"B4","doi-asserted-by":"publisher","first-page":"996","DOI":"10.18632\/oncotarget.27956","article-title":"Perioperative changes in the plasma metabolome of patients receiving general anesthesia for pancreatic cancer surgery","volume":"12","year":"2021","journal-title":"Oncotarget"},{"key":"B5","doi-asserted-by":"publisher","first-page":"584","DOI":"10.1016\/j.surg.2016.11.014","article-title":"The 2016 update of the international study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after","volume":"161","author":"Bassi","year":"2017","journal-title":"Surgery"},{"key":"B6","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1016\/j.ijsu.2018.01.041","article-title":"The outcomes and complications of pancreaticoduodenectomy (whipple procedure): cross sectional study","volume":"52","author":"Karim","year":"2018","journal-title":"Int J Surg"},{"key":"B7","doi-asserted-by":"publisher","first-page":"652","DOI":"10.1097\/00000539-199909000-00022","article-title":"Which clinical anesthesia outcomes are important to avoid? The perspective of patients","volume":"89","author":"Macario","year":"1999","journal-title":"Anesth Analg"},{"key":"B8","doi-asserted-by":"publisher","first-page":"768","DOI":"10.1213\/ANE.0000000000007183","article-title":"Anesthetic techniques and cancer outcomes: what is the current evidence?","volume":"140","author":"Ramly","year":"2025","journal-title":"Anesth Analg"},{"key":"B9","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1038\/nrclinonc.2017.194","article-title":"Perioperative events influence cancer recurrence risk after surgery","volume":"15","author":"Hiller","year":"2018","journal-title":"Nat Rev Clin Oncol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1283","DOI":"10.1007\/s00423-021-02078-z","article-title":"Anaesthesia as an influence in tumour progression","volume":"406","author":"Pl\u00fccker","year":"2021","journal-title":"Langenbecks Arch Surg"},{"key":"B11","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1016\/j.bjae.2018.09.008","article-title":"The impact of anaesthetic technique upon outcome in oncological surgery","volume":"19","author":"Evans","year":"2019","journal-title":"BJA Educ"},{"key":"B12","doi-asserted-by":"publisher","first-page":"4513","DOI":"10.7150\/jca.57661","article-title":"Positive impact of intraoperative epidural ropivacaine infusion on oncologic outcomes in pancreatic cancer patients undergoing pancreatectomy: a retrospective cohort study","volume":"12","author":"Chen","year":"2021","journal-title":"Cancer"},{"key":"B13","doi-asserted-by":"publisher","first-page":"110023","DOI":"10.1016\/j.jclinane.2020.110023","article-title":"Effect of regional anaesthesia only versus general anaesthesia on cancer recurrence rate: a systematic review and meta-analysis with trial sequential analysis","volume":"67","author":"Ang","year":"2020","journal-title":"J Clin Anesth"},{"key":"B14","first-page":"125","article-title":"Pancreaticoduodenectomy under epidural anesthesia without endotracheal intubation for the elderly","volume":"80","author":"Nakashima","year":"1995","journal-title":"Int Surg"},{"key":"B15","first-page":"158","article-title":"The feasibility of epidural anesthesia without endotracheal intubation for abdominal surgery in patients over 80 years of age","volume":"79","author":"Ueo","year":"1994","journal-title":"Int Surg"},{"key":"B16","doi-asserted-by":"publisher","first-page":"481","DOI":"10.1007\/s13304-022-01437-9","article-title":"Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients","volume":"75","author":"Rocca","year":"2023","journal-title":"Updates Surg"},{"key":"B17","doi-asserted-by":"publisher","first-page":"e018787","DOI":"10.1136\/bmjopen-2017-018787","article-title":"Epidurals in pancreatic resection outcomes (E-PRO) study: protocol for a randomised controlled trial","volume":"8","author":"Pak","year":"2018","journal-title":"BMJ Open"},{"key":"B18","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1016\/j.sopen.2022.07.004","article-title":"The clinical impact of the perioperative epidural anesthesia on surgical outcomes after pancreaticoduodenectomy: a retrospective cohort study","volume":"10","author":"Negrini","year":"2022","journal-title":"Surg Open Sci"},{"key":"B19","doi-asserted-by":"publisher","first-page":"4269","DOI":"10.3390\/cancers16244269","article-title":"Anesthetic approaches and their impact on cancer recurrence and metastasis: a comprehensive review","volume":"16","author":"Choi","year":"2024","journal-title":"Cancers (Basel)"},{"key":"B20","doi-asserted-by":"publisher","first-page":"6205","DOI":"10.3390\/jcm13206205-","article-title":"Enhanced recovery after surgery (ERAS) in pancreatic surgery: the surgeon\u2019s point of view","volume":"13","author":"Longo","year":"2024","journal-title":"J Clin Med"},{"key":"B21","doi-asserted-by":"publisher","first-page":"e0233598","DOI":"10.1371\/journal.pone.0233598","article-title":"Propofol-based intravenous anesthesia is associated with better survival than desflurane anesthesia in pancreatic cancer surgery","volume":"15","author":"Lai","year":"2020","journal-title":"PLoS One"},{"key":"B22","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1186\/s12871-022-01703-8","article-title":"The outcome of intravenous and inhalation anesthesia after pancreatic cancer resection: a retrospective study","volume":"22","author":"Ren","year":"2022","journal-title":"BMC Anesthesiol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"798","DOI":"10.1213\/ANE.0000000000006812","article-title":"Thoracic epidural analgesia is not associated with improved survival after pancreatic surgery: long-term follow-up of the randomized controlled PAKMAN trial.","volume":"140","author":"Klotz","year":"2025","journal-title":"Anesth Analg"},{"key":"B24","doi-asserted-by":"publisher","first-page":"719","DOI":"10.1097\/MPA.0000000000001311","article-title":"Epidural analgesia improves postoperative pain control but impedes early discharge in patients undergoing pancreatic surgery","volume":"48","author":"Kim","year":"2019","journal-title":"Pancreas"},{"key":"B25","doi-asserted-by":"publisher","first-page":"547","DOI":"10.1002\/bjs.4881","article-title":"Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical whipple resection-long term results","volume":"92","author":"Seiler","year":"2005","journal-title":"Br J Surg"},{"key":"B26","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.hpb.2021.05.014","article-title":"Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay","volume":"24","author":"Takchi","year":"2022","journal-title":"HPB (Oxford)"},{"key":"B27","doi-asserted-by":"publisher","first-page":"63","DOI":"10.6092\/1590-8577\/1223","article-title":"A fast track recovery program significantly reduces hospital length of stay following uncomplicated pancreaticoduodenectomy","volume":"14","author":"Nikfarjam","year":"2013","journal-title":"JOP"},{"key":"B28","doi-asserted-by":"publisher","first-page":"3685","DOI":"10.3760\/cma.j.issn.0366-6999.20130826","article-title":"Risk factors associated with postoperative hospital stay after pancreaticoduodenectomy: a retrospective study","volume":"126","author":"Xie","year":"2013","journal-title":"Chin Med J (Engl)"},{"key":"B29","doi-asserted-by":"publisher","first-page":"845","DOI":"10.3390\/jpm14080845","article-title":"Emergency awake laparotomy using neuraxial anaesthesia: a case series and literature review","volume":"14","author":"Leoni","year":"2024","journal-title":"J Pers Med"},{"key":"B30","doi-asserted-by":"publisher","first-page":"782336","DOI":"10.3389\/fmed.2021.782336","article-title":"Association between epidural analgesia and cancer recurrence or survival after surgery for renal cell carcinoma: a propensity weighted analysis","volume":"9","author":"Yen","year":"2022","journal-title":"Front Med"}],"container-title":["Frontiers in Surgery"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2025.1675019\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,8]],"date-time":"2025-10-08T05:38:49Z","timestamp":1759901929000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2025.1675019\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,8]]},"references-count":30,"alternative-id":["10.3389\/fsurg.2025.1675019"],"URL":"https:\/\/doi.org\/10.3389\/fsurg.2025.1675019","relation":{},"ISSN":["2296-875X"],"issn-type":[{"value":"2296-875X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,8]]},"article-number":"1675019"}}