Survival outcomes following total intravenous versus volatile anesthesia in esophagogastric cancer surgery: a systematic review and meta-analysis.

Abstract

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. Total intravenous anesthesia (TIVA) has been proposed to exert immunomodulatory and antitumor effects compared to volatile anesthesia (VA), although evidence remains inconclusive. This systematic review and meta-analysis aimed to evaluate the impact of TIVA versus volatile anesthesia on survival outcomes in patients undergoing esophagogastric cancer surgery.

Methods: A systematic review and meta-analysis was conducted according to PRISMA 2020 guidelines. PubMed and Scopus were searched for studies published between 2010 and 2025 comparing TIVA with volatile anesthesia in adult patients undergoing curative surgery for esophageal or gastric cancer. The primary outcome was overall survival (OS). Secondary outcomes included recurrence-free survival (RFS), early mortality, operation time, and postoperative hospital stay. Pooled hazard ratios (HR), risk ratios (RR), and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models.

Results: Thirteen studies (3 randomized controlled trials and 10 retrospective studies) involving 264,543 patients were included. Of these, 41,977 patients received TIVA and 222,566 received volatile anesthesia. Pooled analysis of eight studies demonstrated significantly improved overall survival with TIVA (HR 0.80, 95% CI 0.69-0.93; p = 0.003). Subgroup analysis showed a significant survival benefit in patients undergoing gastrectomy (HR 0.74, 95% CI 0.60-0.91; p < 0.004), whereas no significant difference was observed for esophagectomy (HR 0.89, 95% CI 0.73-1.10; p = 0.29). TIVA was associated with non-significant trends toward improved recurrence-free survival (HR 0.91, 95% CI 0.77-1.06; p = 0.22) and reduced early mortality (HR 0.90, 95% CI 0.77-1.05; p = 0.17). No statistically significant differences were observed in operation time (MD - 3.81 min, 95% CI - 10.75 to 3.13) or hospital stay (MD - 0.19 days, 95% CI - 0.39 to 0.00; p = 0.06).

Conclusions: TIVA may be associated with improved long-term survival outcomes compared with volatile anesthesia in patients undergoing esophagogastric cancer surgery, particularly among patients undergoing gastrectomy. Given the predominance of retrospective evidence and methodological heterogeneity, further high-quality prospective randomized studies are required to clarify the oncological impact of anesthetic techniques in upper gastrointestinal cancer surgery.