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
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).
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