COLORECTAL RESEARCH STUDIES Extralevator abdominoperineal excision (Elape): A retrospective cohort study

  • View
    0

  • Download
    0

Embed Size (px)

Text of COLORECTAL RESEARCH STUDIES Extralevator abdominoperineal excision (Elape): A retrospective cohort...

  • COLORECTAL RESEARCH

    STUDIES

    DR VINAY RATNALIKAR

    CONSULTANT ANAESTHETIST

    ABM UNIVERSITY HEALTH BOARD

    SWANSEA

  • • Aggregation of marginal gains’ for better

    patient outcomes

    • Recognition and correction of anaemia

    • Intravenous lidocaine for pain relief

    • Abdominoperineal resection in lithotomy

    versus prone position

    • HIIT versus aerobic exercise effectiveness in

    perioperative period

    COLORECTAL RESEARCH

    STUDIES

  • Pre-habilitation:

    Editorial in Anaesthesia

  • Cycling = Paddling

    But perioperative care is complex

    The Principle of Aggregation of

    Marginal Gains

    ?is it so

  • Cycling = Paddling

    But perioperative care is complex

    By definition, application of marginal gains

    must begin with the breaking down and

    identification of every tiny step and

    component of the larger process

    ?is it so

  • Does this theory apply to perioperative

    care?

    appropriate patient selection during the pre-

    operative phase;

    carbohydrate loading and goal-directed fluid

    therapy in the operative period;

    and multi-modal analgesia and early

    mobilisation in postoperative period

  • Marginal gains yet to be made?

    In pre-operative period: correction of anaemia,

    optimisation of underlying medical

    comorbidities in an evidence-based manner

    and smoking cessation.

    The concept of short-term pre-operative

    exercise interventions, enabling significant

    improvements in aerobic fitness, is a

    new(ish)concept and appears appealing.

  • HIIT V Aerobic ?

    When compared with moderate continuous exercise training in high-risk cardiac populations, HIIT has delivered significantly superior fitness improvements and is more enjoyable to participating individuals .

    MERITS OF EXERCISE THERAPY BEFORE AND AFTER MAJOR SURGERY

    Current Opinion in Anaesthesiology, April 2014

  • Components to be explored for marginal

    gains

    Assessment and correction of frailty

    Preoperative nutritional improvement

  • International consensus statement on the peri-

    operative management of anaemia and iron

    deficiency

    Anaesthesia: February 2017

  • Iron deficiency

    Iron is the most common and widespread nutritional deficiency, even in industrialised countries, Iron deficiency, with or without anaemia, is associated with chronic conditions such as

    cancer 43%,

    inflammatory bowel disease 45%

    chronic kidney disease 24–85%,

    chronic heart failure 43–100% ……..

  • Role of Iron

    Erythropoiesis

    Oxygen transport

    Mitochondrial respiration

    Gene regulation and cellular immunity

    Increased duration of SIRS in deficiency

  • Iron Stores

    For a 70-kg man, total body iron is about 3500 mg (50 mg/Kg)

    Most of the iron in the body is distributed in haemoglobin within red blood cell (65%; 2300 mg).

    Approximately 10% is found in muscle fibres (in myoglobin) and other tissues (in enzymes and cytochromes) (350 mg).

    Remaining iron stored in the liver, macrophages and bone marrow (850 mg).

  • Daily Requirement

    20 to 30 Mg for production of RBC:

    macrophages recycling iron from senescent red

    blood cells (RBC),

    while daily iron absorption (1–2 mg) balances

    daily losses.

  • Recommendations

    Physicians, Anaesthetists and Managers

    Expected blood loss more than 0.5Lit

    Serum ferritin ≤ 30mcg/l (not in inflammation)

    Major non-urgent surgery

    Treatment target of 130g/l

  • Recommendations

    Oral iron replacement - with or without anaemia

    whose surgery is scheduled 6–8 weeks after

    diagnosis, preferably by the primary care

    physician (General Practitioner).

    7 Daily 40–60 mg or alternate-day 80–100 mg

    nutritional advice

  • Recommendations

    Sufficient data exist to support intravenous iron

    as efficacious and safe. Intravenous iron should

    be used as front-line therapy in patients who do

    not respond to oral iron or are not able to

    tolerate it, or if surgery is planned for < 6 weeks

    after the diagnosis of iron deficiency

  • Recommendations

    Inpatients

    CosmoFer

    Low MW Iron Dextran

    Dose calculator

    COSMOFER@PHARMACOSMOS.COM

    mailto:cosmofer@pharmacosmos.com mailto:cosmofer@pharmacosmos.com mailto:cosmofer@pharmacosmos.com mailto:cosmofer@pharmacosmos.com mailto:cosmofer@pharmacosmos.com

  • Recommendations

    Outpatients

    MonoFer

    Iron Isomaltoside 1000

  • IV lidocaine for acute pain: an evidence

    based clinical update

    BJA Education April2016

  • IV lidocaine for acute pain: an evidence

    based clinical update

    Opioid monotherapy limitations

    Lidocaine:

    Antiinflamatory, Antihyparalgesic

    GI pro-peristaltic

    Decreased pain scores, opioid use and side

    effects

    DIMINISHED REQUIREMENT AND RELIANCE ON OPIOIDS

  • IV lidocaine for acute pain: an evidence

    based clinical update

    WHY LIDOCAINE ?

    IT HAS BEEN SHOWN TO IMPROVE IMPORTANT

    ERAS OUTCOMES—

    EARLY AMBULATION AND FEEDING

    EARLY FITNESS FOR DISCHARGE AND

    INCREASED PATIENT SATISFACTION.

  • IV lidocaine for acute pain: Pharmacology

    Amide (CONH2)

    Acts on Na channels

    Analgesic, anti-hyperalgesic and anti-

    inflammatory properties

    Prevents central sensitisation and reduces

    NMDA depolarisation

  • IV lidocaine for acute pain: Dose

    Bolus 1 to 2 mg/Kg followed by

    0.5 to 5 mg/Kg/hr

    Liver – metabolic capacity as well as BF

    Context sensitive half life

    Metabolites

  • IV lidocaine for acute pain: Safety Profile

    Plasma Concentrations:

    Therapeutic 2.5 to 3.5 mcg/ml

    CNS toxicity 6mcg/ml

    CVS toxicity 10mcg/ml (Contrast

    Bupivacaine)

  • IV lidocaine for acute pain: CR Surgery

    Kaba & colleagues:

    45 Pts colonic resection

    Placebo V i.v. lidocaine (1.5mg – 2mg)

    Better pain scores

    Reduced analgesic requirements

    Lower MAC (Awareness monitoring)

  • IV lidocaine for acute pain: Epidural

    Lidocaine V Epidural:

    Thoracic epidural – Gold standard for

    open surgery

    i.v. lidocaine may offer a useful

    alternative, especially when epidurals are

    contraindicated, refused, or fail.

  • IV lidocaine for acute pain: Ottawa

    Experience

    Since 2009 – protocol for surgical wards

    Continuous ECG monitoring not necessary

    All types of surgery performed

    169 patients, half laparotomies

    6 showed signs of toxicity

    Improvement in dynamic pain scores

  • IV lidocaine for acute pain: Ottawa

    Experience without an initial bolus, the levels of lidocaine

    increase gradually over 4 h and then stabilize at ∼8 h .

    They remain stable over the next few days in the

    models and then rapidly decline upon

    discontinuation of the infusion

    We find this pharmacokinetic model reassuring

    and in keeping with our current clinical practice

  • Prone Position for APR for Rectal Cancer

    Traditional APR

    Some studies claim better results in prone

    (Jack Knife) position

  • Prone Position for APR for Rectal Cancer

    Diseases of Colon and Rectum 2011

    (Luiz Felipe et al, Cleveland, Ohio)

    Surgical positioning during perineal part of

    APR does not affect periop morbidity or

    oncologic outcomes and…….

    It should be left to the surgeon’s

    discretion!!!

  • Prone Position for APR for Rectal Cancer

    Extralevator abdominoperineal excision

    (Elape): A retrospective cohort study

    (Annals of Medicine and Surgery 2016)

    Short term results from this study support

    that ELAPE has better oncological

    outcome.

  • Prone Position for APR for Rectal Cancer

    Better operative outcomes achieved with

    the prone jack-knife vs. lithotomy position

    during abdominoperineal resection in

    patients with low rectal cancer

    (Liu et al. World Journal of Surgical

    Oncology - 2015)

  • Prone Position for APR for Rectal Cancer

    Duration of surgery,

    hospital stay,

    blood transfusion,

    post-op complications – better

    But…

  • Prone Position for APR for Rectal Cancer

    There were no significant differences in

    overall