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!"#$%&'(&)*+,

AIVOC : anesthésie intra-veineuse à objectif de concentration

ALR : anesthésie loco-régionale

APD : anesthésie péridurale

ASA : American Society of Anesthesiology

BPCO : bronchopneumopathie chronique obstructive

CRP : protéine C réactive

FiO2 : fraction inspirée en oxygène

IMC : indice de masse corporelle en kg/m2

IV : intraveineux

NLR : neutrophils to lymphocytes ratio, rapport neutrophiles/lymphocytes

NO2 : protoxyde d’azote

OMS : Organisation Mondiale de la Santé

PCT : procalcitonine

SFAR : Société Française d’Anesthésie Réanimation

SIRS : syndrome de réponse inflammatoire systémique

SOFA : sequential organ failure assessment

TAP Block : transverse abdominal plain block

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20

-'"./,0/+,1'(&2#/+,

1.! Introduction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"##!

2! Matériels et méthodes"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"#$!

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3! Résultats"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"%%!

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4! Discussion"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"&#!

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5! Conclusion"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"&'!

6! Annexes"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"()!

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7! Résumé"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"V)!

8! Bibliographie"!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"V#!

!

21

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22

1.! Introduction !

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24

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25

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26

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!

!

!

!

27

2 Matériels et méthodes !

0>BB>!HBJ?>V!:KE:EFH>!:CK!;@H_J9:>!?J!?H:CKB>=>DB!?@+D>FBGHF9>I'HCD9=CB9ED!?J!0O"!?>!(C9DBI

&B9>DD>V!?9K9\H>!:CK!;>!QK!2E;;9>cV!>FB!JD>!HBJ?>!?>!TEGEKB>!E`F>KXCB9EDD>;;>!:KEF:>TB9X>!

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T>DBK>F!GEF:9BC;9>KF!SKCDrC9FZ!

2.1! Objectifs de l’étude

2.1.1! Objectif principal

1@E`Y>TB9S!:K9DT9:C;!?>!DEBK>!BKCXC9;!HBC9B!?@HXC;J>K!;@>SS>B!?>!;@CD>FBGHF9>!:HK9?JKC;>!>D!

TE=:;H=>DB!?>!;@CD>FBGHF9>!\HDHKC;>!FJK!;C!FJKX>DJ>!?@JD>!;[=:GE:HD9>!>D!:EFB!E:HKCBE9K>!?>!

TG9KJK\9>!TCKT9DE;E\9_J>!BGEKCT9_J>!>B!?9\>FB9X>Z!

2.1.2! Objectifs secondaires

1>F!E`Y>TB9SF!F>TED?C9K>F!HBC9>DB!3!!

I! ?@HXC;J>K!;C!:KESED?>JK!C9DF9!_J>!;C!T9DHB9_J>!?>!FJKX>DJ>!?>!;C!;[=:GE:HD9>!>D!:EFB!

E:HKCBE9K>V!

I! ?@HXC;J>K!;C!FJKX>DJ>!?>!TE=:;9TCB9EDF!9DS>TB9>JF>F!TG>]!;>F!:CB9>DBF!>D!:EFB!E:HKCBE9K>!

F>;ED!;@JB9;9FCB9ED!EJ!DED!?@JD>!CD>FBGHF9>!:HK9?JKC;>!>D!TE=:;H=>DB!?>!;@CD>FBGHF9>!

\HDHKC;>Z!

2.2! Population

2.2.1! Critères d’inclusion

)EJB!:CB9>DB!=CY>JK!`HDHS9T9CDB!?@JD>!TG9KJK\9>!TCKT9DE;E\9_J>!?9\>FB9X>!EJ!BGEKCT9_J>!

:KE\KC==H>!FEJF!CD>FBGHF9>!\HDHKC;>Z!

28

2.2.2! Critères de non inclusion

#>!:EJXC9>DB!^BK>!9DT;JF!3!

I!:CB9>DB!=9D>JKV!FEJF!BJB>;;>!EJ!9DTC:C`;>!?@>c:K9=>K!FED!TEDF>DB>=>DB!HT;C9KH!

I!S>==>!>DT>9DB>!

I!GH=E:CBG9>!CTB9X>!!

I!:CB9>DB!C[CDB!`HDHS9T9H!?@JD>!C;;E\K>SS>!

I!HBCB!F>:B9_J>!EJ!('$(!:KHE:HKCBE9K>Z!

!

2.3! Prélèvements réalisés

! 1C!XC;>JK!:KHE:HKCBE9K>!?J!BCJc!?>!;[=:GET[B>F!HBC9B!K>;>XH>!FJK!;>!`9;CD!`9E;E\9_J>!

:KHE:HKCBE9K>!SC9B!N!WI6!EJ!W5Z!1>F!XC;>JKF!:EFBIE:HKCBE9K>F!?J!BCJc!?>!;[=:GET[B>F!HBC9>DB!K>;>XH>F!

>D!:EFB!E:HKCBE9K>!FJK!;>F!`9;CDF!`9E;E\9_J>F!F[FBH=CB9_J>F!SC9BF!N!W6V!WeV!Wg!>B!WMZ!!

2.4! Origine et nature des données recueillies !

1>F!?EDDH>F!K>TJ>9;;9>F!FJK!;C!:E:J;CB9ED!HBJ?9H>!HBC9>DB!;>F!FJ9XCDB>F!3!!!

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(TEK>!?>!;@+=>K9TCD!(ET9>B[!ES!+D>FBG>F9E;E\9FBF!a+(+b!

)C`C\9F=>!CTB9S!

29

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!

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30

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31

$DS>TB9ED!?J!F9B>!E:HKCBE9K>!

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=>BBCDB!>D!HX9?>DT>!;>!\>K=>!K>F:EDFC`;>Z!!

!

2.5! Mode de circulation des données

! 1>F!?EDDH>F!EDB!HBH!K>TJ>9;;9>F!>B!>DK>\9FBKH>F!FJK!;>!;E\9T9>;!9DSEK=CB9_J>!'>?TC:!FEJF!SEK=>!

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1>!SEK=J;C9K>!TE=:;>B!?>!K>TJ>9;!?>!?EDDH>F!>FB!?9F:ED9`;>!>D!CDD>c>!6Z!!

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BGRF>!C:KRF!;C!S9D!?>!;C!:HK9E?>!?>!K>TJ>9;Z!!

!

2.6! Durée et modalités d’organisation de la recherche

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?>XCDB!`HDHS9T9>K!?@JD>!TG9KJK\9>!?9\>FB9X>!EJ!BGEKCT9_J>!TCKT9DE;E\9_J>!EDB!HBH!FH;>TB9EDDHF!C:KRF!

XHK9S9TCB9ED!?>F!TK9BRK>F!?@9DT;JF9ED!>B!?>!DED!9DT;JF9EDZ!

1>F!:CB9>DBF!HBC9>DB!9DSEK=HF!?>!SCrED!EKC;>!>B!HTK9B>!;EKF!?>!;@9DT;JF9EDZ!$;F!F9\DC9>DB!JD!

TEDF>DB>=>DB!HT;C9KH!N!;>JK!:CKB9T9:CB9EDZ!

32

1>!FJ9X9!`9E;E\9_J>!HBC9B!KHC;9FH!?JKCDB!M!YEJKF!EJ!YJF_J@N!;C!FEKB9>!?@GEF:9BC;9FCB9ED!F9!T>;;>IT9!

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TG9KJK\9>!EJ!?>!FE9DF!9DB>DF9SFLKHCD9=CB9EDZ!!

!

2.7! Méthode d’analyse des données

1@CFFET9CB9ED!?>F!SCTB>JKF!?>!K9F_J>!HBJ?9HF!CX>T!;C!FJKX>DJ>!?@JD>!9DS>TB9ED!:EFB!E:HKCBE9K>!C!

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FBCB9FB9_J>!l!,9EFBC).%!m!

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FEDB!>c:K9=H>F!>D!DE=`K>!aDb!>B!:EJKT>DBC\>!ahbZ!!

!

2.8! Éthique

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>B!;>!00)$'(!;>!66!CXK9;!456qZ!

!

!

!

!

!

!

!

!

33

3! Résultats

3.1! Description de la population étudiée.

! &DBK>!CXK9;!456q!>B!CXK9;!456dV!64M4!:CB9>DBF!EDB!HBH!9DT;JF!?CDF!4g!T>DBK>F!GEF:9BC;9>KF!

SKCDrC9FZ!1>F!:CB9>DBF!9DT;JF!HBC9>DB!=CYEK9BC9K>=>DB!?>F!GE==>FZ!1@u\>!=E[>D!HBC9B!?>!qq!v!66!CDFZ!

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:CB9>DBF!?>!;C!TEGEKB>!HBC9>DB!SJ=>JKF!CTB9SF!CJ!=E=>DB!?>!;C!TG9KJK\9>Z!

! 1>F!TCKCTBHK9FB9_J>F!TE=:;RB>F!?>!;C!:E:J;CB9ED!9DT;JF>!?CDF!;C!TEGEKB>!&%+1s2QO!FEDB!

KHFJ=H>F!?CDF!;>!BC`;>CJ!6Z!!

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34

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!

35

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!

!

!

36

!9J3594%]%P%/<>@4@C>5:%;<A@96>D45:F%

!

!

3.2! Résultat principal : anesthésie péridurale et lymphopénie post

opératoire.

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:HK9?JKC;>Z!

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37

3.3! Résultats secondaires

3.3.1! Caractéristiques de la prise en charge anesthésique.

!

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TEGEKB>V!;@>DBK>B9>D!CD>FBGHF9_J>!C!HBH!SC9B!:CK!QKE:ESE;!+$%-0Z!!

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! 1C!c[;ETCpD>!$%!HBC9B!JB9;9FH>!?CDF!e4Vgh!?>F!TCFZ!1@CDB9`9E:KE:G[;Cc9>!HBC9B!KHC;9FH>!TG>]!;C!

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eqV480!v!5VdeZ!

38

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!

3.3.2! Complications infectieuses post opératoire.

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39

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3.3.3! Lymphopénie post opératoire.

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40

3.3.4! Anesthésie péridurale et complications infectieuses.

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41

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42

4! Discussion !

! #EBK>!HBJ?>!C!:>K=9F!?@9DT;JK>!CJ!BEBC;!64M4!:CB9>DBFV!9FFJF!?>!46!T>DBK>F!GEF:9BC;9>KF!

SKCDrC9FV!FJK!JD>!:HK9E?>!?>!:;JF!?@JD>!CDDH>Z!0GC_J>!T>DBK>!KC::EKBC9B!?>F!:KCB9_J>F!CD>FBGHF9_J>F!

?9SSHK>DB>FV!F>;ED!;>F!GC`9BJ?>F!;ETEKH\9EDC;>F!>D!CD>FBGHF9>!KHCD9=CB9EDV!DEJF!:>K=>BBCDB!?>!

K>TJ>9;;9K!JD>!9=:EKBCDB>!?9X>KF9BH!?>!:K9F>F!>D!TGCK\>!CD>FBGHF9_J>FV!DEBC==>DB!?CDF!;>F!

?9SSHK>DB>F!B>TGD9_J>F!?@CD>FBGHF9>!;ETEIKH\9EDC;>!JB9;9FH>F!>B!?CDF!;@>DBK>B9>D!?>!;@CD>FBGHF9>!

aJB9;9FCB9ED!?J!QKE:ESE;!+$%-0!EJ!?>!;@>DBK>B9>D!9DGC;CBE9K>bZ!1>!DE=`K>!?>!:CB9>DBF!9DT;JF!HBC9B!CJI

?>;N!?J!DE=`K>!?>!FJY>BF!DHT>FFC9K>F!TC;TJ;H!;EKF!?>!;C!KHC;9FCB9ED!?J!:KEBETE;>!?>!K>TG>KTG>!CX>T!

BEJB>SE9F!JD!BCJc!?>!TE=:;9TCB9EDF!9DS>TB9>JF>F!;H\RK>=>DB!9DSHK9>JK!CJc!45h!CBB>D?JF!9D9B9C;>=>DBZ!

1>!TCKCTBRK>!DCB9EDC;!?>!;@HBJ?>!C9DF9!_J>!;C!=J;B9:;9T9BH!?>F!T>DBK>F!C[CDB!:KETH?H!N!?>F!9DT;JF9EDF!

DEJF!:>K=>BBC9B!?@CJ\=>DB>K!DEBK>!K>:KHF>DBCB9X9BH!?>!;C!:E:J;CB9ED!\HDHKC;>!>D!TG9KJK\9>!

TCKT9DE;E\9_J>V!?>!:CK!;C!?9X>KF9BH!?J!K>TKJB>=>DB!C9DF9!_J>!?>F!9DB>KX>DB9EDF!TG9KJK\9TC;>FZ!"D>!?>F!

:K9DT9:C;>F!SEKT>F!?>!DEBK>!BKCXC9;!KHF9?C9B!?CDF!;@HBJ?>!?>!:;JF9>JKF!B[:>F!?>!TG9KJK\9>F!

TCKT9DE;E\9_J>F!3!?9\>FB9X>F!>B!BGEKCT9_J>FZ!QEJK!T>F!9DB>KX>DB9EDFV!;>F!:KETH?JK>F!TG9KJK\9TC;>F!

HBC9>DB!=J;B9:;>F!CX>T!?@JD>!:CKB!T>KBC9DF!\>FB>F!KHC;9FHF!:CK!B>TGD9_J>F!X9?HEI\J9?H>F!aTz;9EFTE:9>F!

>B!BGEKCTEFTE:9>Fb!?9B>F!l!=9D9I9DXCF9X>F!m!>B!?@CJBK>!:CKB!?>F!TG9KJK\9>F!:CK!BGEKCTEBE=9>!>B!

;C:CKEBE=9>!TEDF9?HKH>F!TE==>!:;JF!9DXCF9X>FZ!1C!?9X>KF9BH!?>F!\>FB>F!TG9KJK\9TCJc!DEJF!EDB!:>K=9F!

?@9DT;JK>!CJFF9!`9>D!?>F!TG9KJK\9>F!>cBK^=>=>DB!;EJK?>F!>B!9DXCF9X>F!_J>!?>F!\>FB>F!:;JF!;H\>KF!>B!

KC:9?>FZ!WJF_J�N!:KHF>DBV!;C!;9BBHKCBJK>!KHT>DB>!FJK!;>!FJY>B!F>!;9=9BC9B!N!?>!:>B9B>F!HBJ?>FV!;>!:;JF!

FEJX>DB!=EDET>DBK9_J>FV!D@9DT;JCDB!_J>!_J>;_J>F!?9]C9D>F!?>!:CB9>DBFZ!

0>!\KCD?!HX>DBC9;!?>!:KETH?JK>F!TG9KJK\9TC;>FV!?>!B>TGD9_J>F!CD>FBGHF9_J>F!\HDHKC;>F!

TE=`9DHF!N!?9X>KF!\>FB>F!?@CD>FBGHF9>!;ETEKH\9EDC;>!>FB!JD>!SEKT>!=CY>JK>!?>!DEBK>!HBJ?>V!;J9!

TEDSHKCDB!;C!:J9FFCDT>!DHT>FFC9K>!:EJK!HBJ?9>K!;>!;9>D!>DBK>!;@CD>FBGHF9>!:HK9?JKC;>V!;[=:GE:HD9>!

:EFB!E:HKCBE9K>!>B!TE=:;9TCB9EDF!9DS>TB9>JF>F!C:KRF!TG9KJK\9>!TCKT9DE;E\9_J>Z!!

43

1@CDC;[F>!FBCB9FB9_J>!D>!:>K=>B!:CF!?>!=>BBK>!>D!HX9?>DT>!?>!?9=9DJB9ED!?>!;C!;[=:GE:HD9>!

:EFB!E:HKCBE9K>!TG>]!;>F!:CB9>DBF!`HDHS9T9CDB!?@JD>!CD>FBGHF9>!:HK9?JKC;>!>D!TE=:;H=>DB!?>!

;@CD>FBGHF9>!\HDHKC;>!:EJK!;C!TG9KJK\9>!TCKT9DE;E\9_J>Z!-D!K>BKEJX>!CJ!TEDBKC9K>!JD>!:;JF!\KCD?>!

:KE:EKB9ED!?>!:CB9>DBF!;[=:GE:HD9_J>F!?CDF!;>!\KEJ:>!CD>FBGHF9>!:HK9?JKC;>!:CK!KC::EKB!CJ!\KEJ:>!

FCDF!CD>FBGHF9>!:HK9?JKC;>!afqh!?>!:CB9>DBF!;[=:GE:HD9_J>F!N!W6!?CDF!;>!\KEJ:>!FCDF!CD>FBGHF9>!

:HK9?JKC;>!X>KFJF!g4h!?CDF!;>!\KEJ:>!C[CDB!`HDHS9T9H!?@JD>!CD>FBGHF9>!:HK9?JKC;>bZ!"D>!>c:;9TCB9ED!

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?>F!9DB>KX>DB9EDF!TG9KJK\9TC;>F!:;JF!;EJK?>F!>B!9DXCF9X>F!?>!B[:>!;C:CKEBE=9>!>B!BGEKCTEBE=9>V!CX>T!

JD>!CBB>9DB>!?>F!SEDTB9EDF!9==JD9BC9K>F!>B!?EDT!?@JD>!;[=:GE:HD9>!:EFB!E:HKCBE9K>!:;JF!9=:EKBCDB>!

:EJK!T>!B[:>!?>!TG9KJK\9>!a46V44V4ebZ!1@9DS;J>DT>!?>!;@CD>FBGHF9>!:HK9?JKC;>!FJK!;C!SEDTB9ED!

;[=:GET[BC9K>!K>FB>!N!?H=EDBK>K!FJK!?>!\KCD?F!>SS>TB9SF!?>!:CB9>DBFZ!$;!F>KC!9DBHK>FFCDB!?>!TE=:CK>K!

:EJK!JD!=^=>!B[:>!?>!TG9KJK\9>!;@>SS>B!?>!;@CD>FBGHF9>!:HK9?JKC;>!FJK!;C!SEDTB9ED!;[=:GET[BC9K>V!>D!

KHC;9FCDB!JD>!HBJ?>!TE=:CKCB9X>!CD>FBGHF9>!\HDHKC;>!CX>T!:HK9?JKC;>!X>KFJF!CD>FBGHF9>!\HDHKC;>!

F>J;>!:EJK!JD!=^=>!B[:>!?>!TG9KJK\9>V!CS9D!?>!F@CSSKCDTG9K!?J!`9C9F!9D?J9B!:CK!?>F!:KETH?JK>F!

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9==JD9BC9K>FZ!

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44

#EF!KHFJ;BCBF!>D!B>K=>!?>!T9DHB9_J>!>B!?>!:KESED?>JK!?>!;[=:GE:HD9>!:EFB!E:HKCBE9K>!FEDB!

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KHCFT>DF9ED!?>F!;[=:GET[B>F!X>KF!;C!XC;>JK!:KHE:HKCBE9K>Z!+!WM!:EFB!E:HKCBE9K>V!;>!BCJc!?>!

;[=:GET[B>F!HBC9B!>DTEK>!C`C9FFH!?>!6dh!>D!=E[>DD>!:CK!KC::EKB!CJ!BCJc!:KHE:HKCBE9K>V!C;EKF!_J>!

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!

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45

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ae4bZ!!

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46

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47

9==JDEI=E?J;CB>JKF!:KE:K>F!?EDB!;@9DS;J>DT>!FJK!;>!?HT;9D!;[=:GET[BC9K>!C!HBH!?H=EDBKH!a4qV4MVedbZ!

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?>!;@CD>FBGHF9>!:HK9?JKC;>Z!!

!

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TE=:;H=>DBC9K>!CX>T!DEF!?EDDH>F!:EKBCDB!FJK!64M4!:CB9>DBFZ!

! 1>F!HBJ?>F!N!X>D9K!?>XKEDB!H\C;>=>DB!9DBH\K>K!BEJF!;>F!B[:>F!?>!TG9KJK\9>F!TCKT9DE;E\9_J>F!

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;>F!SCTB>JKF!?>!K9F_J>!?@9DS>TB9ED!:EFB!E:HKCBE9K>Z!

!

!

!

!

48

4.1! Point sur l’étude Evalymph

1@HBJ?>!?>!TEGEKB>!&XC;[=:G!FJK!;C_J>;;>!DEJF!DEJF!FE==>F!`CFHF!:EJK!DEBK>!BKCXC9;!C!

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456MZ!!1>F!TEDT;JF9EDF!FEDB!K>BKCDFTK9B>F!B>;;>F!_J@>;;>F!S9\JK>DB!?CDF!;@C`FBKCTBZ!

%9D\BIBKE9F!T>DBK>F!GEF:9BC;9>KF!JD9X>KF9BC9K>F!>B!:K9XHF!SKCDrC9F!EDB!:CKB9T9:H�!N!;@HBJ?>V!

:>K=>BBCDB!;@9DT;JF9ED!?>!6e5q!:CB9>DBFZ!(JK!T>F!6e5q!:CB9>DBFV!46f!a6qhb!EDB!:KHF>DBH!JD>!

TE=:;9TCB9ED!9DS>TB9>JF>Z!!

+:KRF!CDC;[F>!JD9XCK9H>!:J9F!=J;B9XCK9H>V!EDB!HBH!K>B>DJF!TE==>!SCTB>JKF!?>!K9F_J>!?@9DS>TB9ED!:EFB!

E:HKCBE9K>!3!;>!TE=:B>!;[=:GET[BC9K>!N!W6V!;C!TG9KJK\9>!EJX>KB>!a;C:CKEBE=9>LBGEKCTEBE=9>bV!;>!FTEK>!

+(+!x!eV!;C!,Q0-!>B!;C!?JKH>!?>!TG9KJK\9>Z!1@CDC;\HF9>!:HK9?JKC;>!BGEKCT9_J>!EJ!;E=`C9K>!D>!?9=9DJ>!

:CF!;>!K9F_J>!?@9DS>TB9ED!?CDF!T>BB>!CDC;[F>Z!

1>F!:K9DT9:CJc!KHFJ;BCBF!FEDB!K>:K9F!?CDF!;>!BC`;>CJ!FJ9XCDB!3!

!!

!

!

49

5! Conclusion !

#EBK>!HBJ?>V!:EKBCDB!FJK!JD>!TEGEKB>!?>!64M4!:CB9>DBFV!C!:>K=9F!?>!TEDS9K=>K!;C!FJKX>DJ>!

?@JD>!;[=:GE:HD9>!>D!:EFBIE:HKCBE9K>!?>!TG9KJK\9>F!TCKT9DE;E\9_J>F!BGEKCT9_J>F!>B!?9\>FB9X>F!CX>T!

JD>!TGJB>!?J!BCJc!?>!;[=:GET[B>F!?>!e6h!?RF!W6!FJ9X9>!?@JD>!;>DB>!KHCFT>DF9ED!YJF_J@CJ!BCJc!:KHI

E:HKCBE9K>Z!1@C;BHKCB9ED!?>!;C!SEDTB9ED!;[=:GET[BC9K>!>D!:EFBIE:HKCBE9K>!>DBKC�D>!JD>!

9==JDEFJ::K>FF9ED!BKCDF9BE9K>!K>F:EDFC`;>!?@JD>!=CYEKCB9ED!?J!K9F_J>!?>!TE=:;9TCB9EDF!

9DS>TB9>JF>F!TG>]!;>F!:CB9>DBF!;[=:GE:HD9_J>FZ!1C!;9BBHKCBJK>!K>BKEJX>!?>!DE=`K>Jc!`HDHS9T>F!N!

;@JB9;9FCB9ED!?@JD>!CD>FBGHF9>!:HK9?JKC;>!>D!TE=:;H=>DB!?>!;@CD>FBGHF9>!\HDHKC;>!?CDF!;C!

:KHF>KXCB9ED!?>!;C!SEDTB9ED!;[=:GET[BC9K>Z!!!

#EJF!CXEDF!HXC;JH!;C!;[=:GE:HD9>!:EFB!E:HKCBE9K>!>DBK>!?>Jc!\KEJ:>F!?>!:CB9>DBF!3!JD!\KEJ:>!

TE=:K>DCDB!;>F!TG9KJK\9>F!CX>T!CD>FBGHF9>!:HK9?JKC;>!>B!;@CJBK>!FCDFZ!1@CDC;[F>!FBCB9FB9_J>!D@C!:CF!:J!

=>BBK>!>D!HX9?>DT>!?@9DS;J>DT>!`HDHS9_J>!?>!;@CD>FBGHF9>!:HK9?JKC;>!JB9;9FH>!>D!TE=:;H=>DB!?>!

;@CD>FBGHF9>!\HDHKC;>!FJK!;C!FJKX>DJ>!?@JD>!;[=:GE:HD9>!>D!:EFBIE:HKCBE9K>Z!1@C`F>DT>!?>!KHFJ;BCB!

F9\D9S9TCB9S!>D!B>K=>!?>!?9=9DJB9ED!?>!;[=:GE:HD9>!:EFBIE:HKCBE9K>!:EJKKC9B!^BK>!?J>!N!;C!DED!

TE=:CKC`9;9BH!?>F!?>Jc!\KEJ:>FV!;>!\KEJ:>!CX>T!CD>FBGHF9>!:HK9?JKC;>!TE=:K>DCDB!?>F!TG9KJK\9>F!

:;JF!;EJK?>F!_J>!;>!\KEJ:>!CD>FBGHF9>!\HDHKC;>!F>J;>Z!!

1@CDC;[F>!FBCB9FB9_J>!D>!K>BKEJX>!:CF!DED!:;JF!?@CFFET9CB9ED!FBCB9FB9_J>=>DB!F9\D9S9TCB9X>!

>DBK>!;@JB9;9FCB9ED!?>!;@CD>FBGHF9>!:HK9?JKC;>!>B!;C!?9=9DJB9ED!?>F!TE=:;9TCB9EDF!9DS>TB9>JF>F!>D!:EFBI

E:HKCBE9K>!?>!TG9KJK\9>F!BGEKCT9_J>F!>B!?9\>FB9X>FZ!

#EJF!D@CXEDF!:CF!:J!?H=EDBK>K!?>!SCrED!FBCB9FB9_J>=>DB!F9\D9S9TCB9X>!?@9=:CTB!?>!

;@CD>FBGHF9>!:HK9?JKC;>!F>J;>!FJK!;C!:KHF>KXCB9ED!?>!;C!SEDTB9ED!;[=:GET[BC9K>!>B!FJK!;>F!TE=:;9TCB9EDF!

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50

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ETUDE EVALYMPH

FICHE DE RECUEIL DE DONNEES

INFORMATIONS LIEES AU PATIENT 3 premières lettre du nom … 2 premières lettre du prénom .. Numéro OBSERVATION REDCAP (obtenu lors de la saisie informatique) : Année de naissance : SEXE : F M TAILLE (cm) : POIDS (kg) : IMC (calcul automatique masse(Kg)/taille (m)2

SCORE ASA: I II III IV V Score de Charlson Tumeur solide métastatique O N SIDA O N Maladie hépatique modérée à sévère O N Hémiplégie O N Maladie rénale modérée à sévère O N Diabète avec atteinte d'un organe cible O N N'importe quelle tumeur O N Leucémie O N Lymphome O N Infarctus du myocarde aigu O N Insuffisance cardiaque congestive O N Maladie vasculaire périphérique O N AVC O N Démence O N Maladie chronique pulmonaire O N Connectivite O N Maladie ulcéreuse O N Maladie hépatique légère O N Diabète O N PERFORMANCE STATUS OMS : OMS 0 = personne normale – activité physique intacte- efforts possibles sans limitation.

OMS 1 = réduction des efforts – autonomie complète.

OMS 2 = personne encore autonome – se fatigue facilement – nécessité de se reposer plus de

6 heures par jour.

OMS 3 = personne dépendante – levé possible- ne fait pas sa toilette seule.

OMS 4 = dépendance totale – quasi grabataire.

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DIABETE TRAITE: O N Insuline : O N

BPCO: O N CIRRHOSE: O N INSUFFISANCE RENALE DIALYSEE O N TABAGISME ACTIF : O N ALBUMINEMIE (g/l) : O N PERTE de POIDS RECENTE d’au moins 10% : O N ETAT IMMUNITAIRE PRE OPERATOIRE CHIMIOTHERAPIE < 6 MOIS : O N RADIOTHERAPIE <6 MOIS : O N IMMUNONUTRITION PRE OPERATOIRE (type Oral Impact®) : O N SONDAGE A DEMEURE (préopératoire) : O N Prise d’AINS dans les 7 jours précédant la chirurgie O N

Corticothérapie 7 jours précédant la chirurgie O N

Si OUI posologie : ≥ 1mg/kg <1mg/kg

Corticothérapie per et post opératoire O N

Si OUI posologie : ≥ 1mg/kg <1mg/kg

Pas d’infection pré-opératoire O N

CHIRURGIE DATE DE LA CHIRURGIE : jj/mm/aaaa Chirurgie digestive : O N

Oesophagienne, Gastrique, hépato-biliaire, pancréatique, duodéno-iléo-jéjunale, rectocolique (un choix à valider)

Chirurgie thoracique : O N Pneumonectomie, bilobectomie, lobectomie, wedge resection (un choix à valider) LAPARO-/THORACOTOMIE : O N LAPARO-/THORACOSCOPIE : O N Classification Altemeier : 1 2 3 4 Classe 1= chirurgie propre

Classe 2 = chirurgie propre contaminée (ex ouverture viscère creux avec contamination

minime)

Classe 3 = chirurgie contaminée

Classe 4 = chirurgie sale (contamination fécale, viscère perforé)

CLASSIFICATION CANCER STADE 1 Cancer in situ (non invasif) STADE 2 cancer localisé, sans métastases à distance ni extension ganglionnaire STADE 3 atteinte ganglionnaire satellite STADE 4 Tumeur avancée localement et/ou métastases à distance

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ANESTHESIE Antibioprophylaxie : O N ANESTHÉSIE GENERALE : O N

ENTRETIEN PROPOFOL : O N ENTRETIEN HALOGENÉ : O N

ANESTHÉSIE PERIMÉDULLAIRE : O N LOMBAIRE O N THORACIQUE O N

AUTRE ALR : O N SI OUI LAQUELLE (en clair) :

LIDOCAINE IV : O N FIO2 MOYENNE (%) : NO2 : O N DUREE ANESTHÉSIE (min): DUREE CHIRURGIE ( min) : TRANSFUSION PER OPERATOIRE, SSPI : O N NOMBRE DE CGR (n) : Température fin d’intervention (en clair) : DONNEES BIOLOGIQUES

NFP AUX DIFFERENTS TEMPS : J-1/J0 J1 J3 J5 J8

LEUCOCYTES (G/l)

MONOCYTES (G/l)

POLYNUCLEAIRES NEUTROPHILES (G/l)

POLYNUCLEAIRES EOSINOPHILES (G/l)

LYMPHOCYTES (G/l)

HEMATOCRITE

PLAQUETTES

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COMPLICATIONS INFECTIEUSES : (pendant la durée de l’hospitalisation) SRIS : O N date de survenue (jj/mm/aaaa) : Au moins 2 des critères suivants :

Température > 38,3°C OU < 36°C

Fréquence cardiaque > 90 b/min

Fréquence respiratoire > 20 c/min

Glycémie > 7,7 mmol/l

Leucocytes > 12000 /mm3 ou < 4000 /mm3 ou > 10 % de formes immatures

Altération des fonctions supérieures

Temps de recoloration capillaire > 2 s

Lactatémie > 2 mmol/l

SEPSIS : O N date de survenue (jj/mm/aaaa) : Réponse inflammatoire systémique + infection présumée ou identifiée

SEPSIS SEVERE : O N date de survenue (jj/mm/aaaa) : Sepsis + lactatémie > 4 mmol/l ou hypotension artérielle avant remplissage ou dysfonction

d’organe (une seule suffit) :

Respiratoire PaO2/FiO2 < 300

Rénale : créatininémie > 176 micromol/l

Coagulation : INR > 1,5

Hépatique : INR > 4, bilirubine > 78 micromol/l

Thrombocytopénie : < 105 /mm3

Fonctions supérieures : score de coma Glasgow < 13

CHOC SEPTIQUE : O N date de survenue (jj/mm/aaaa) : Sepsis grave + hypotension artérielle malgré le remplissage vasculaire (20-40 ml/kg)

INFECTION DU SITE OPERATOIRE : O N date de survenue (jj/mm/aaaa) : Infection superficielle de l'incision : O N Infection survenant dans les 30 jours suivant l'intervention, et affectant la peau (ou les

muqueuses), les tissus sous-cutanés ou les tissus situés au dessus de l'aponévrose de

revêtement, associée à au moins un des éléments suivants:

écoulement purulent de l'incision

micro-organisme associé à des polynucléaires neutrophiles à l’examen direct, isolé par

culture obtenue de façon aseptique du liquide produit par une incision superficielle ou d'un

prélèvement tissulaire.

ouverture de l’incision par le chirurgien et présence de l'un des signes suivants : douleur ou

sensibilité à la palpation, tuméfaction localisée, rougeur, chaleur

Une culture bactérienne négative, en l’absence de traitement antibiotique, exclut le cas.

L'inflammation minime confinée aux points de pénétration des sutures ne doit pas

être considérée comme une infection.

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Infection profonde (de l'incision ou de l’organe-espace) O N

Infection survenant dans les 30 jours suivant l'intervention affectant les tissus ou organes ou

espaces situés au niveau ou au dessous de l'aponévrose de revêtement, ou encore ouverts ou

manipulés durant l’intervention, associée à au moins un des éléments suivants: Ecoulement purulent provenant d'un drain sous-aponévrotique Déhiscence spontanée de l’incision ou ouverture par le chirurgien et au moins un des signes suivants : fièvre > 38°C douleur localisée, sensibilité à la palpation une culture négative, en l’absence de traitement antibiotique, exclut le cas. Abcès ou autres signes d'infection observés lors d'une réintervention chirurgicale, d'un examen histopathologique, d’un examen d’imagerie ou d’un acte de radiologie interventionnelle. PERITONITE SECONDAIRE : O N Date de survenue (jj/mm/aaaa) Lâchage d’anastomose O N Lâchage de suture O N Lâchage de moignon O N Iatrogène : perforation per endoscopique, ou radiologie interventionnelle

O N AUTRE INFECTION : O N Date de survenue (jj/mm/aaaa) Abcès organe O N Abcès sous phrénique O N Pleurésie purulente O N Hémocultures positives O N PNEUMOPATHIE : O N date de survenue (jj/mm/aaaa) Anomalie sur la radiographie pulmonaire de type infiltrat ou opacité pulmonaire, de novo ou

modification d’une image existante

ET Fièvre > 38,5°C ou < 36°

Associés à l’un des 3 critères suivants :

Elévation de la CRP

Ou élévation des leucocytes à un taux supérieur à 12 G/L ou < 4 G/L

Ou augmentation du caractère purulent des expectorations

INFECTION URINAIRE: O N Date de survenue (jj/mm/aaaa)

Au moins un des signes suivants :

fièvre (> 38°C), impériosité mictionnelle, pollakiurie, brûlure mictionnelle, ou douleur sus-

pubienne, en l’absence d’autre cause, infectieuse ou non.

Et :

Sans sondage vésical ni autre abord de l’arbre urinaire : leucocyturie (≥ 104 leucocytes/ml)

et uroculture positive (≥ 103 micro-organismes/ml) et au plus 2 micro-organismes différents,

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Avec sondage vésical ou autre abord de l’arbre urinaire, en cours ou dans les 7 jours

précédents : uroculture positive (≥ 105 micro-organismes/ml) et au plus 2 micro-organismes

différents.

DOCUMENTATION BACTERIOLOGIQUE : O N Type de germe : (en clair) DOCUMENTATION VIROLOGIQUE : O N Type de virus (en clair) : DOCUMENTATION MYCOLOGIQUE : O N Type de mycose (en clair) : Reprise chirurgicale O N date de la reprise : jj/mm/ aaaa DATE DEBUT ALIMENTATION PARENTERALE : jj/mm/ aaaa DATE REPRISE ALIMENTATION ENTERALE : jj/mm/ aaaa SEJOUR en SOINS INTENSIFS/REANIMATION en POSTOPERATOIRE immédiat : O N durée (j) : SEJOUR en SOINS INTENSIFS/REANIMATION après un retour dans le service de chirurgie O N (durée j) : DUREE HOSPITALISATION (j) : DECES INTRA- HOSPITALIER: O N

Cause: (en clair)

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8! Bibliographie 1. Kluytmans JA, Mouton JW, Maat AP, Manders MA, Michel MF, Wagenvoort JH. Surveillance of postoperative infections in thoracic surgery. J Hosp Infect. juin 1994;27(2):139!47. 2. Pessaux P, Msika S, Atalla D, Hay J-M, Flamant Y, French Association for Surgical Research. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg. mars 2003;138(3):314!24. 3. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. nov 1999;20(11):725!30. 4. Badia JM, Casey AL, Petrosillo N, Hudson PM, Mitchell SA, Crosby C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect. mai 2017;96(1):1!15. 5. Guillou PJ. Biological variation in the development of sepsis after surgery or trauma. Lancet. 24 juill 1993;342(8865):217!20. 6. Walton B. Anaesthesia, surgery and immunology. Anaesthesia. avr 1978;33(4):322!48. 7. Duncan PG, Cullen BF. Anesthesia and immunology. Anesthesiology. nov 1976;45(5):522!38. 8. Kremer MJ. Surgery, pain, and immune function. CRNA. août 1999;10(3):94!100. 9. Ogawa K, Hirai M, Katsube T, Murayama M, Hamaguchi K, Shimakawa T, et al. Suppression of cellular immunity by surgical stress. Surgery. mars 2000;127(3):329!36. 10. Takahashi J, Shono Y, Hirabayashi H, Kamimura M, Nakagawa H, Ebara S, et al. Usefulness of white blood cell differential for early diagnosis of surgical wound infection following spinal instrumentation surgery. Spine. 20 avr 2006;31(9):1020!5. 11. Kennedy BC, Hall GM. Neuroendocrine and inflammatory aspects of surgery: do they affect outcome? Acta Anaesthesiol Belg. 1999;50(4):205!9. 12. Hogan BV, Peter MB, Shenoy HG, Horgan K, Hughes TA. Surgery induced immunosuppression. Surgeon. févr 2011;9(1):38!43. 13. Vallejo R, Hord ED, Barna SA, Santiago-Palma J, Ahmed S. Perioperative immunosuppression in cancer patients. J Environ Pathol Toxicol Oncol. 2003;22(2):139!46. 14. Elenkov IJ, Wilder RL, Chrousos GP, Vizi ES. The sympathetic nerve--an integrative interface between two supersystems: the brain and the immune system. Pharmacol Rev. déc 2000;52(4):595!638.

15. Inagi T, Suzuki M, Osumi M, Bito H. Remifentanil-based anaesthesia increases the incidence of postoperative surgical site infection. J Hosp Infect. janv 2015;89(1):61!8. 16. Inagi T, Hoshina H, Suzuki M, Wada M, Bito H, Sakamoto A. Remifentanil-induced alterations in neutrophil numbers after surgery. JA Clin Rep. 2016;2(1):5. 17. Kurosawa S. Anesthesia in patients with cancer disorders. Curr Opin Anaesthesiol. juin 2012;25(3):376!84. 18. Kurosawa S, Kato M. Anesthetics, immune cells, and immune responses. J Anesth. 2008;22(3):263!77. 19. Lim J-A, Oh C-S, Yoon T-G, Lee JY, Lee S-H, Yoo Y-B, et al. The effect of propofol and sevoflurane on cancer cell, natural killer cell, and cytotoxic T lymphocyte function in patients undergoing breast cancer surgery: an in vitro analysis. BMC Cancer. 07 2018;18(1):159. 20. Hu X, Tang H, Zhou Z, Yin F, Liu W. [The effect of sevoflurane inhalation anesthesia only and propofol total intravenous anesthesia on perioperative cytokine balance in lung cancer patients]. Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi. juin 2011;27(6):659!61. 21. Peng Y-P, Qiu Y-H. [Surgical stress and immunosuppression]. Sheng Li Ke Xue Jin Zhan. janv 2006;37(1):31!6. 22. Lennard TW, Shenton BK, Borzotta A, Donnelly PK, White M, Gerrie LM, et al. The influence of surgical operations on components of the human immune system. Br J Surg. oct 1985;72(10):771!6. 23. Leaver HA, Craig SR, Yap PL, Walker WS. Lymphocyte responses following open and minimally invasive thoracic surgery. Eur J Clin Invest. mars 2000;30(3):230!8. 24. Gomatos IP, Alevizos L, Kalathaki O, Kantsos H, Kataki A, Leandros E, et al. Changes in T-Lymphocytes’ Viability After Laparoscopic Versus Open Cholecystectomy. Int Surg. avr 2015;100(4):696!701. 25. Gennari R, Dominioni L, Imperatori A, Bianchi V, Maroni P, Dionigi R. Alterations in lymphocyte subsets as prognosticators of postoperative infections. Eur J Surg. juill 1995;161(7):493!9. 26. Enigk F, Wagner A, Samapati R, Rittner H, Brack A, Mousa SA, et al. Thoracic epidural anesthesia decreases endotoxin-induced endothelial injury. BMC Anesthesiol. 2014;14:23. 27. Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 5 janv 2016;(1):CD005059. 28. Volk T, Schenk M, Voigt K, Tohtz S, Putzier M, Kox WJ. Postoperative epidural anesthesia preserves lymphocyte, but not monocyte, immune function after major spine surgery. Anesth Analg. avr 2004;98(4):1086!92, table of contents.

29. Kawasaki T, Ogata M, Kawasaki C, Okamoto K, Sata T. Effects of epidural anaesthesia on surgical stress-induced immunosuppression during upper abdominal surgery. Br J Anaesth. févr 2007;98(2):196!203. 30. Welden B, Gates G, Mallari R, Garrett N. Effects of anesthetics and analgesics on natural killer cell activity. AANA J. août 2009;77(4):287!92. 31. Tyagi A, Bansal A, Das S, Sethi AK, Kakkar A. Effect of thoracic epidural block on infection-induced inflammatory response: A randomized controlled trial. J Crit Care. 2017;38:6!12. 32. Cummings KC, Zimmerman NM, Maheshwari K, Cooper GS, Cummings LC. Epidural compared with non-epidural analgesia and cardiopulmonary complications after colectomy: A retrospective cohort study of 20,880 patients using a national quality database. J Clin Anesth. 2018;47:12!8. 33. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 23 févr 2016;315(8):801!10. 34. Nesseler N, Matthay MA, Seguin P, Nesseler N. Choc septique : définitions, épidémiologie, monitorage et principes thérapeutiques. :20. 35. Eisenstein TK, Hilburger ME. Opioid modulation of immune responses: effects on phagocyte and lymphoid cell populations. J Neuroimmunol. 15 mars 1998;83(1!2):36!44. 36. Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth. déc 2011;107(6):859!68. 37. Hong J-Y, Lim KT. Effect of preemptive epidural analgesia on cytokine response and postoperative pain in laparoscopic radical hysterectomy for cervical cancer. Reg Anesth Pain Med. févr 2008;33(1):44!51. 38. Mohri Y, Tanaka K, Toiyama Y, Ohi M, Yasuda H, Inoue Y, et al. Impact of Preoperative Neutrophil to Lymphocyte Ratio and Postoperative Infectious Complications on Survival After Curative Gastrectomy for Gastric Cancer: A Single Institutional Cohort Study. Medicine (Baltimore). mars 2016;95(11):e3125. 39. Kim WH, Jin HS, Ko JS, Hahm TS, Lee SM, Cho HS, et al. The effect of anesthetic techniques on neutrophil-to-lymphocyte ratio after laparoscopy-assisted vaginal hysterectomy. Acta Anaesthesiol Taiwan. sept 2011;49(3):83!7.

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RESUME : La chirurgie digestive et thoracique à visée carcinologique est une thérapeutique agressive avec des procédures chirurgicales et anesthésiques lourdes. Elle est fréquemment grevée de complications infectieuses, ayant pour retentissement un allongement des durées d’hospitalisation et une augmentation de la morbi-mortalité. Les lymphocytes étant responsables de l’immunité à médiation cellulaire, nous avons étudié l’influence de l’anesthésie péridurale sur la lymphopénie et les complications infectieuses survenant en post opératoire de chirurgie carcinologique thoracique et digestive. Il s’agit d’une étude de cohorte observationnelle, prospective, multicentrique incluant 1282 patients opérés d’un cancer thoracique ou digestif. Un suivi biologique est effectué à J1, J3, J5 et J8 ainsi qu’un suivi clinique jusqu’à sortie d’hospitalisation. L’objectif principal est d’évaluer l’influence de l’anesthésie péridurale en complément de l’anesthésie générale sur la survenue d’une lymphopénie et de complications infectieuses en post opératoire de chirurgie carcinologique thoracique et digestive. 1282 patients ont été inclus dans l’étude, 456 ont bénéficié d’une anesthésie péridurale pour la chirurgie. Une lymphopénie post opératoire a été mise en évidence avec une diminution moyenne de 31% du taux de lymphocytes à J1. Il n’a pas été mis en évidence d’effet protecteur l’anesthésie péridurale sur la lymphopénie et les complications infectieuses post opératoire. Notre étude n’a pas permis de mettre en évidence un effet bénéfique de l’anesthésie péridurale sur la préservation de la fonction lymphocytaire ou sur la survenue de complications infectieuses en post opératoire de chirurgies carcinologiques thoraciques et digestives. Rubrique de classement : Anesthésie-réanimation

Mots-clés : Anesthésie péridurale, Lymphocytes, Chirurgie carcinologique, Infections post opératoire, Chirurgie thoracique, Chirurgie digestive. Président : Pr Paul-Michel MERTES Assesseurs : Pr Olivier COLLANGE, Pr Annick STEIB , Pr Anne OLLAND, Dr Clément BONGARZONE Adresse de l'auteur : Gauthier VINEE 7 Quai Mathiss 67000 STRASBOURG

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