Optimoitu toipuminen, kirurgin näkökulma

Tom Scheinin, kirurgian dosentti, FRCS

Sidonnaisuudet kahden viimeisen vuoden ajalta

•  LKT, kirurgian ja gastroenterologisen kirurgian erikoislääkäri, kirurgian dosentti, lääkärikouluttajan erityispätevyys

•  Päätoimi –  HY, Kliininen opettaja

•  Sivutoimet –  HYKS, erikoislääkäri, osaston vastuulääkäri –  yksityislääkäri Eiran sairaala

•  Tutkimus ja kehitystyö –  Kliininen tutkimus tyrä- sappi- ja suolistokirurgiasta

•  Koulutustoiminta –  Luentoja eri lääkealan yritysten koulutuksissa (Olympus, Aesculap Academy, Takeda) –  Osallistunut lääkealan yrityksen koulutusten suunnitteluun ( BBraun) –  Suomen Gastrokirurgit Ry lukukausittain toistuvien erikoistuvien laparoskopiakurssien vetäjä –  Suomen Gastrokirurgien ja Gastroenterologiayhdistyksen koulutusvaliokunnan jäsen

•  Luottamustoimet terveydenhuollon alalla -  ESCP Board of trustees -  AGC-Course Davos, faculty member -  Suomen Gastrokirurgit, pj -  Suomen Kirurgiyhdistys, hallituksen jäsen

•  Toiminta terveydenhuollon ohjaukseen pyrkivissä hankkeissa –  HYKS operatiivisten toimintojen sijoittumistyöryhmä

•  Muut sidonnaisuudet –  Osakkeenomistaja Eiran sairaala

Fast track

Fast track = Lentokentät = LP I = Päivystyksen hoitopolku = Kaikkea muuta, ei kirurgiaa

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study

In a randomized, observer-and-patient, blinded trial, 60 patients (median age 75 years) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours. Basse L et al. Ann Surg 2005;241:416-23

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study

•  30 open

–  OR time 131,5 min –  Discharge 2,3 pop –  Re-admitted 8 (27%)

•  30 laparoscopic

–  OR 215,5 min –  Discharge 2,9 pop –  Re-admitted 6 (20%)

Basse L et al. Ann Surg 2005;241:416-23

OT (ERAS)

Pre-operatiiviset

tekijät

Anestesia Intra-

operatiiviset ja kirurgiset

Post-operatiiviset

Evidence Based Medicine

Wind J et al. Br J Surg 2006;93:800-809 Systematic review of enhanced recovery programmes in colonic surgery

17 ERAS items 5 or more ERAS items = ERAS programme

ERAS-criteria PRE-OP WARD •  Patient information •  Avoid fasting •  Synbiotics •  No bowel-prep

ANAESTHESIA •  No opioid/benzo premedication •  Limited iv fluids •  O2 0.6 - 0.8 •  Avoiding hypothermia •  Epidural analgesia •  Minimise need of opioids •  Avoid NG-tube

SURGERY •  Mini-invasive/transverse incisions •  Avoid drains

POST-OP WARD •  Early mobilisation •  Early enteral nutrition •  Laxative •  Early removal of urinary catheter

Wind J et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006

Laparoscopic pelvic surgery

•  steep Trendelendburg •  blood pressure •  placement of epidural •  gastric reflux (NG)

•  IAP - CO2 •  diuresis •  compression of veins •  compression of lungs •  atelectasis

LAPAROSCOPIC SURGERY IMPAIRS TISSUE OXYGEN TENSION

Home day 3 postop

2005-2008

Home day 4 postop

2000-2005

www.erassociety.org

ERAS society recommendations Evidence level and recommendation grade

Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

•  Info: low, strong •  No bowelprep: high, strong •  Preop limited fasting and carbohydrate treatment:

– Fasting: moderate, strong – Carbohydrate loading: low, strong

•  Preop optimisation: – Prehab: low, no – Alcohol: low, strong – Smoking: high, strong

ERAS society recommendations Evidence level and recommendation grade

Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

•  No long acting sedatives: high, strong •  DVT propylaxis: high, strong •  Antibiotics and skinprep: high, strong •  Standard anaesthesia protocol:

– Rapid awakening: low, strong – Reduce stress response: moderate, strong – Open surgery: high, strong – Lap surgery: moderate, strong – Multimodal approach to PONV: low, strong

ERAS society recommendations Evidence level and recommendation grade

Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

•  Laparoscopy and modified access: –  Oncology: high, strong –  Morbidity: Low, strong –  Recovery: moderate, strong

•  Nasogastric tube: high, strong •  Avoid hypothermia: high, strong •  Periop fluid management: high, strong •  No routine drainage: high, strong •  Urinary drainage 1-2 d: low, strong (epidural!)

ERAS society recommendations Evidence level and recommendation grade

Gustafsson UO et al. Guidelines for perioperative care in Elective colonic surgery: ERAS society recommendations. World J Surg 2013

•  Avoiding ileus: –  Thoracic epidural lap: high, strong –  Chewing gum: moderate, strong –  Oral magnesium, alvidopan: low, weak/strong

•  Postop analgesia: –  TEA, open surgery: high, strong –  TEA not essential in lap: moderate, strong –  Local anaesthetic & opioid: moderate, strong –  NSAID/paracetamol: moderate, strong

Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective

randomized study Turunen P et al, Surg Endosc. 2009 Jan;23(1):31-7. Epub 2008 Sep 24

•  60 patients with complicated diverticular disease: with or without epidural anesthesia

•  Postoperative oxycodone consumption, pain, and recovery parameters were followed for 14 days

Turunen P et al, Surg Endosc. 2009 Jan;23(1):31-7. Epub 2008 Sep 24

Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective

randomized study

op time (min) blood loss (ml) Bowel/air (d) Bowel/feces (d) hospital stay (d) readmission (n)

Epidural 135 (60-165) 20 (20-800) 1 (1-4) 2 (1-7) 3 (2-9) 3

No epidural 120 (85-230) 20 (20-200) 1 (1-4) 2 (1-9) 3 (1-14) 1

CONCLUSIONS:

•  Epidural analgesia significantly alleviates pain, reducing the need for opioids during the first 48 h after laparoscopic sigmoidectomy.

•  However, epidural analgesia does not alter postoperative oral intake, mobilization, or length of hospital stay

Diuresis with or without epidural

0.01 3 ± 4 8 ± 9 Oksicodon (mg) ‏

±31CRP (mg/l)) 66(‏ ±36) 51(‏ 0.03

0.01 4.7±0.9 5.5±1.5 Fluids (l/d) ‏

0.05 83±29 69±25 Diuresis (ml/h) ‏

0.053 26 (±17) 18 (±12) Efedrin (mg)

P Epidural Controls Day of operation

Randomized Clinical Trial on Epidural Versus Patient-Controlled Analgesia for Laparoscopic Colorectal Surgery

Within an Enhanced Recovery Pathway

•  128 patients undergoing elective laparoscopic colorectal resection

•  Epidural or PCA

Hübner M et al, Ann Surg 2014

Results:

•  Recovery required a median of 5 days in EDA patients and 4 days in the PCA group, P = 0.082

•  PCA patients had significantly less overall complications;19 (33%) vs 35 (54%); P = 0.029

Hübner M et al, Ann Surg 2014

Conclusions:

•  Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits

•  EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery

Hübner M et al, Ann Surg 2014

- pre- vai postop - korkeus - opiaatti - puudute

SIC! Mikä epiduraali käytössä:

Home day 2-4 postop

2008 -

Criteria for going home Patient eats, drinks, bowel and diuresis function, pain manageable with oral painkillers, no nausea, staying at home feasible