The whole world now is directed to implement strategies that enhance the patient's
quality of life and prevent tumor relapse , so the Enhanced recovery after pancreatic
surgery (ERAPS) program was found to improve the quality of life as it is an
evidence-based protocol designed to standardize and optimize perioperative medical care
in order to reduce surgical trauma, perioperative physiological stress, organ
dysfunction, reduction of clinical complications, length of hospital stay and the health
costs together with increase of patient satisfaction.
ERAPS was applied for pancreatic surgery in 2012, since that time 27 developed ERAPS
items were evaluated, 5 of them got the highest level of evidence those include (avoiding
hypothermia, use of wound catheters for continuous analgesia, antimicrobial,
thromboprophylaxis protocols and preoperative nutritional interventions for patients with
severe weight loss (15%). ERAS society encourages further researches to improve
compliance and outcome and to confirm the benefit of current updated recommendations.
Many drugs had been used in the anaesthetic management of major abdominal surgeries and
of which is lidocaine; it is an amide local anaesthetic commonly used for regional and
neuraxial blocks. Recently its use as intravenous perioperative infusion for abdominal
cancer surgeries is encouraging, as it significantly reduces postoperative pain, opioid
consumption and nausea and vomiting. it also promotes gastrointestinal function recovery,
and shortens the postoperative hospital stay.
In addition, lidocaine in particular can act directly and indirectly on pancreatic cancer
cells and the tumor microenvironment. At the tumor level, lidocaine can induce apoptosis
in cancer cells by inhibiting Src phosphorylation and reducing the expression of adhesion
molecules. In the tumor microenvironment, lidocaine can enhance the activity of immune
cells such as natural killer cells, which are responsible for directly attacking cancer
cells. Furthermore the impact of lidocaine on post-operative opioid consumption could be
another factor that reduces the opioid associated cancer progression.
Natural killer (NK) cells are cluster of differentiation 3 (CD3-) -cluster of
differentiation 56 (CD56+) lymphocytes playing a pivotal role in the innate immune
response against cancer. Their main purpose is identification and eradication of virus
infected cells and metastatic cells. Diminished activity of NK cells is a predisposing
factor for cancer recurrence. Preservation of innate immune function and the direct
anti-inflammatory effects may be the cause of the protective effects of local
anaesthetics and regional techniques.
Different concentrations of local anaesthetics appear to have different effects on NK
cytotoxicity. High concentrations of lidocaine suppress NK cell cytotoxicity; yet
clinically relevant concentrations enhance the in vitro function of NK cells via the
release of lytic granules. Hence, lidocaine appears to have predominantly anticancer
effects So the investigators suggest that IV lidocaine infusion in combination with ERAPS
protocol may achieve better postoperative outcomes after pancreatic surgery for cancer.