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

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 survival, disease-free survival, local

recurrence, and distant metastasis (P >

0.05).

THANK YOU