Chebanov K.O., Baranov I.V. Zavizion V,Bondarenko I.Abu Shamsiah R. Novikov S.P.N,F Olefir Y.I., Grishko S.A. Hojouj Mohammad., Vasilishin A.V., Karas R.K.

Optimization of anesthetic management of peri- and postoperative period in patients under surgical treatment of colorectal cancer

Background. At the present stage of medicine development colorectal cancer is an actual medical and socio-economic problem. Because surgical is the primary method of treatment the question of how does method of anesthesia and postoperative analgesia influence the processes of metastasis and survival of cancer patients becomes actual.

Objective. The purpose of research is to select the optimal method of anesthesia protection of patients from operating aggression during surgical treatment of colorectal cancer.

Methods. Performed a comparative analysis of clinical data and results of treatment using total intravenous anesthesia followed analgesia with opiates analgesics, and combined techniques using low-flow sevoflurane anesthesia and epidural analgesia, followed by prolonged epidural anesthesia.

Results. It was shown a significant advantage to combined techniques in comparison with total intravenous anesthesia due to: normodynamic type of hemodynamics during operation, possibility to extubate patient in operating room, effective analgesia in early postoperative period. Methods of prolonged epidural analgesia provided a significant need reduction for opioid analgesics, efficient analgesia in postoperative period, saved anti-tumor immunity and resistance to metastasis in patients with cancer, has provided more early resumption of intestine motor function, reduced terms of patient’s staying in the intensive care unit. Implemented methodology reduced the frequency of postoperative mortality, complications, average length of hospital stay and frequency of patients returns to intensive care unit.

Conclusion. Combined techniques of low-flow sevoflurane anesthesia and epidural analgesia, followed by prolonged epidural anesthesia is an optimal method of anesthesia protection of patients from operating aggression during surgical treatment of colorectal cancer.

Keywords: colorectal cancer, low-flow anesthesia, combined anesthesia, epidural analgesia, sevoflurane.

Communal institution “Dnepropetrovsk City Multidisciplinary Hospital №4» of Dnepropetrovsk regional Council”, Dnepropetrovsk city

 

Introduction

Currently, colon cancer (colorectal) is treated together – and almost always used the term “colorectal cancer”, an increased incidence in recent years, which is celebrated in all economically developed countries. According to the World Health Organization, the world is annually registered more than 500 thousand. Cases of colorectal cancer. Statistical data on the incidence of colorectal cancer in different countries per 100 000 population are not the same: in the United States – 33.2%, Sweden – 17.8%, Great Britain – 25.8%, Japan – 15.7%, Senegal – 2 5% [1].

According to the National Cancer Institute, in spite of all that is undertaken in the fight against cancer rates, the level in 2014 significantly increased [2].

Among the ten major clinical entities in the structure of oncological diseases in Ukraine bowel malignancies occupy 5th place (6.3%) men and 4 th place (6.6%) among women. In the structure of the population of Ukraine onkosmertnosti colorectal cancer is the 4th place (6.3%) among males and 2 nd place among women (8.7%) [2].

The leading method in the treatment of colorectal cancer to date is surgical. These interventions (hemicolectomy, resection, extirpation of the rectum) are a group of highly traumatic, because require surgery involving lymph node dissection, the formation of grafts for sfinkterosohranyayuschih operations. In recent years, attitudes have shifted toward radicalism in regard to operability of patients with malignant tumors of the abdominal cavity in the later stages, the number of extended radical interventions affecting a number of organs and tissues of stress. The massive tissue damage, the more pronounced his accompanying inflammatory response and the intensity of postoperative pain [3].

According to many scientists, the further improvement of surgical techniques and increase in surgical procedures for rectal cancer is futile and will not lead to improved long-term results of treatment. The main reason for the lack of noticeable improvement in the long-term results of treatment of colorectal cancer is the large number of relapses and metastases occur in different periods at the resected patients.

Thus, at the present stage of development of medicine rectal cancer is an urgent medical and social-economic problem due to increased morbidity and mortality, late diagnosis, poor treatment outcomes. Improving long-term results of treatment of colorectal cancer can be achieved by improving the diagnosis of this disease on the one hand, and the development of combined and complex treatment methods – from the other side. Since surgical method is the main method of treating cancer, becomes relevant the question of the effect of the method of anesthesia and postoperative analgesia on the processes of metastasis and survival of cancer patients requiring surgical treatment and thus adequate pain relief.

purpose

Improving the quality of anesthesia to protect patients from operating aggression, ensuring optimal postoperative analgesia, reducing the number of complications, improve the results of surgical treatment of colorectal cancer.

Study Design

Made a comparative analysis of the effectiveness of anesthesia and postoperative peri- period when radical surgical treatment of colorectal cancer.

Robot is made on the basis of the Department of Anesthesiology with 12 beds for intensive care city hospital №4 multidisciplinary Dnepropetrovsk.

Intraoperative hemodynamic parameters were assessed using complex rheographic PeOK XAI-Medic.

We studied 70 patients who had shown radical surgery for colorectal cancer.

Exclusion criteria:

- Health surgery;

- Urgent surgery;

- Decompensated cardiovascular disease;

- Patients who are diagnosed distant metastatic lesions.

The patients were divided into 2 groups:

Group 1:

Anesthetic management: standard ataralgesia (sibazon, fentanyl, thiopental sodium) with myoplegia (ditilin, arduan). Postoperative analgesia: dexketoprofen (Deksalgin) 50 mg / m 3p / day + opioid analgesics (morphine) to reach VAShd to 4 points.

Group 2:

Anesthetic Management: Combined with the use of sevoflurane anesthesia and epidural analgesia. Technically epidural puncture was performed at the level of L1 – L2, followed by catheterization of the epidural space in the cranial direction. Induction: Fentanyl 5,0 mg / kg propofol – 1.5-2.0 mg / kg, mioplegii – ditilin 2 mg / kg. Maintenance of anesthesia was performed using anesthetic Leon station («HEINEN», AUSTRIA), where MAC sevoflurane 0.5-0.6 created in the stream of oxygen-air mixture is 0.8-1.0 l / min in combination with a bolus administration of fentanyl 0 2 mg / hr. Epidurally administered 0.25% bupivacaine (Longokain) in a volume of 12-15 ml containing 0.05 mg of fentanyl. For 30 minutes before the end of surgery in / administered 1000 mg of paracetamol (Infulgan).

Postoperative analgesia: dexketoprofen (Deksalgin) 50 mg / m 2p / day + paracetamol (Infulgan) 1000 mg / 2 p / day + epidural analgesia 10 mg 0.125% bupivacaine (Longokain) every 6 hours + opioid analgesics (morphine) on demand in order to

 

Из представленной таблицы видно, что группы были сопоставимы.

Показатель 1 группа
(атаралгезия)
2 группа
(комбинированная методика)
Пол (м/ж) 21/14 23/12
Возраст 65 ± 4 67 ± 5
Степень операционно-наркозного риска ASA II 22 (63%) 20 (59%)
Степень операционно-наркозного риска ASA III 13 (37%) 15 (41%)
Длительность оперативного вмешательства, часы 3,2 ± 0,9 3,1 ± 0,7

Качественную эффективность аналгезии в послеоперационном периоде оценивали с помощью визуально аналоговой шкалы (ВАШ) (рис. 1).

Рис.1 Визуально-аналоговая шкала

Fig.1 Visual analogue scale

 

Research carried out in pain at rest and when moving the patient. In the first 8-12 hours postoperative pain assessment was conducted every 30 minutes, subsequently – every 2 hours. We focus on the criterion of maximum pain intensity 3 points alone, and 4 points while moving the patient.

Starting from the second day as the standard of care in the postoperative period in both groups, we used a technique of hyperbaric oxygenation. In our practice sessions of HBO carried out in the following way: 1.3-1.5 atm izopressiya 30-40 minutes, 3-5 sessions. This method leads to increase in the partial pressure of oxygen in body fluids, enhances its diffusion in hypoxic tissue site.

 

Results and Discussion

Intraoperative period:

When evaluating hemodynamic parameters at all stages of the research focus shifts mean arterial pressure does not reach the level of confidence (p> 0,05), but in group 2 indicators were below 80-90 mmHg against the group 1 – 95-98 mmHg

In the analysis of heart rate had lower values ​​in the combined anesthesia group (group 1 – 86, Group 2 -78) and 2 hours (group 1 – 86, group 2 – 65) and 3 hours ( Group 1 – 80, group 2 – 67) from the start of surgery observed statistically significant differences (p <0,05).

If we talk about the value of cardiac index SI is clearly observed a downward trend in the group ataralgezii 20% in an hour (Group 1 – 2.8 l / min / m2, the 2nd group – 3,5 l / min / m2 ), and a statistically significant reduction of 30-35% (p <0,05) from the second hour of surgery (group 1 – 2.34 L / min / m 2, Group 2 – 3,56 l / min / m2).

The second component is interconnected with the SI central hemodynamics – the total peripheral vascular resistance SVR. In analyzing the data, we observed a decline in the combined analgesia (Group 1 – 3064-3283din / cm × s-5, Group 2 – 2762-2904din / cm × s-5), but the focus shifts did not reach the degree of reliability (p> 0,05).

In the analysis of the last two indicators of central hemodynamics, namely SI and round, it can be said that the combined analgesia provides eukinetic type of hemodynamics, while in the group ataralgezii tend to her oppression to hypokinesia.

After extubation, we have seen a three-fold reduction in pain VAS values ​​combined anesthesia group (1.53 versus 4.5 points), significantly faster regresirovali signs of residual sedation (20 vs. 148 minutes). Up to 95% of patients were extubated combined techniques in the operating room. In group 2, we observed lower incidence of postoperative shivering, which, in our opinion, due to the low concentration of bupivacaine 0.25%, due to which there is expressed a sympathetic block, the lack of a central inhibition of thermoregulation, fast wake-up period, as well as the quality of analgesia, because postoperative pain and chills often go together.

The recovery rate of mental functions and the effectiveness of pain relief

indicators Клинические группы
1-я группа 2-я группа
Pain at rest after extubation (points) 4,5±0,49 1,53±0,08*
Time regression signs of residual sedation (min) (Polinchuk IS, 2010) 148±39 20±5*
Postanesthetic chills (person /%) 26/74,28% 7/20% *
Extubation in the operating room (person /%) 0 33/94,28%

* – достоверные отличия показателей 2-й группы от 1-й группы (p<0,05).

 

The postoperative period:

In the first group of morphine consumption in the first day amounted to 2,8 ± 0,3 mg, with more than 60% of patients to achieve at least 5 points VAShd took over 2 administrations. On the 2nd day morphine consumption amounted to 1,7 ± 0,25 mg on day 3 mg 1,3 ± 0,2 to achieve VAShd 4-5.

In the second group in the first day, we observed a significant reduction in pain intensity, with it, only 9 patients (25.71%) required a single on / m injection of 10 mg of morphine to achieve VAShd less than 5 points. The next day the severity of pain is not reached by VAShd more than 5 points that did not require additional purpose of opioid analgesics (Fig. 2).

Рис. 2 Динамика выраженности болевого синдрома в послеоперационном периоде

Fig. 2 Dynamics of the severity of pain in postoperative period

 

A significant decrease in the number of opioid analgesics, and the quality of postoperative pain in patients with cancer through the use of regional techniques is especially important because it is .:

  1. reduces the severity of the negative effects of narcotic drugs: respiratory depression, excessive sedation, nausea and vomiting, inhibition of peristalsis, urinary retention, pruritus, hypotension, depending on the development of allergic reactions, reactivation of herpes infections, especially immunosuppression and resistance to metastasize.
  2. We prove the direct influence of agonists μ-opioid receptors in the development and progression of cancer [4, 5].
  3. It is shown that mechanical failure is the suppression of the activity of natural killer (NK) and dissemination of the tumor process in the experiment [6].
  4. Insufficient eliminate postoperative pain leads to an increased risk of the tumor process generalization and increases mortality in breast cancer, head and neck, colon and rectum, lung [7, 8].
  5. Regional analgesia in the peri- and postoperative periods provides: excellent pain relief, improved function of the CAS, earlier mobilization, lower impaired immune responses, fewer thromboembolic complications, less postoperative pulmonary complications, improving the function of the gastrointestinal tract and the postoperative period [9, 10, eleven].
  6. Local anesthetics have anti-inflammatory properties at low AI concentrations inhibit excessive activation PMYAG, their adhesion to endothelial cells, inhibit histamine release by reducing the exudation of plasma components, block the release of leukotriene B4, which, together with a prostaglandin E2 play a major role in the formation of tissue edema, MA positive effect on postoperative intestinal paresis, anti-inflammatory effect of MA is stable and persists through 36 hours after cessation of administration. [12]
  7. Reduced frequency of postoperative thromboembolic complications in the conditions of long-term epidural infusion MA due to: an increase in blood flow in the lower extremities by sympathetic blockade, reduced plasma concentrations of factor VIII and vWF. [8]
  8. Against the background of long EA enhanced fibrinolytic activity due to: prevent the release of proteins, plasminogen activator inhibitor, save the background concentration of plasminogen activator, plasminogen activators increase the synthesis of the vascular endothelium [8].
  9. Antitumor Activity MA (Malachy Columb, 2013): metasticheskie many cancer cells express on their surface the voltage-dependent sodium channels, and the density of expression in the metastatic cells is higher than in the cells of the primary tumor. MA blockade of sodium channels inhibits the ability of metastatic cells to the migration [13].

The emergence of single peristaltic waves in Group 1 was observed during 62 ± 6 hours after laparotomy versus 24 ± 4:00 patients in group 2. Full restoration of the intestine and the discharge of gases in 1-group pointed to 88 ± 48 vs. 5:00 ± 4:00 postoperative period. Accordingly, patients in Group 1 were in the intensive care four days, patients in group 2 were transferred to the profile department on the 3rd day.

Episodes of nausea and vomiting in the early postoperative period in the first group occurred in 13 patients (37.14%) against the second group 3 patients (8.5%).

Against the background of the implemented techniques and tactics of the combined analgesia postoperative analgesia in our hospital during the period from 2012 to 2014. distinct tendency to reduce lethality from 1.5% to 0.6% (60%) reduction in the number of surgical interventions with complications from 11 (1.4%) 9 (1.2%). Reduce the number of readmissions of patients in the intensive care unit with 12 to 1. reduce the average hospital stay of 7.7% from 24.6 to 22.7.

Performance onkoproktologicheskoy service in 2012-2014.

 

 

2012г. 2013г. 2014г.
Послеоперационная летальность 1,5 0,8 0,6
Число операций с осложнениями 11(1,4%) 8(1,1%) 9(1,2%)
Средний койко-день оперированных пациентов 24,6 25,6 22,7
Кол-во возвратов послеоперационных больных в отделения реанимации 12 8 1

 

Findings

  1. At the present stage of development of medicine colorectal cancer is an urgent medical and socio-economic problem. Improving long-term results can be achieved through the development of combined and complex treatment. Since surgical method is the primary method of treatment becomes relevant the question of the effect of the method of anesthesia and postoperative analgesia on the processes of metastasis and survival of cancer patients.
  2. Combined Low-sevoflurane inhalation anesthesia and epidural analgesia with bupivacaine after radical surgery for colorectal cancer has an advantage over all-out / in anesthesia:

- Allows normodynamic type of hemodynamics during the entire operation.

- It provides effective analgesia after extubation

- Provides a fast regression of symptoms of sedation postanesthetic

- Reduces the incidence of postoperative shivering

- Allows you to extubation of the patient in the operating room.

  1. Methods of epidural analgesia in comparison with opiate analgesia provides:

- A significant reduction in the need for opioid analgesics

- Effective and high-quality analgesia in the postoperative period

- Reduces the incidence of nausea and vomiting in the early postoperative period

- Retains the anti-tumor immunity and resistance to metastasis in patients with cancer

- It provides an earlier restoration of motor function of intestinal

- Reduce the length of stay of the patient in intensive care

  1. The implementation of the methodology reduced the incidence of postoperative mortality, complications, average length of hospital stay and frequency of returns of the day patients in the intensive care unit.

Литературные источники

  1. [American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016]. Atlanta: American Cancer Society. 2014: 32.
  2. [National Cancer Registry of Ukraine]. 2015;16. Ukrainian.
  3. Ovechkin A.M., Sviridov S.V. [Post-operative pain and pain management: state of the art]. Medical emergency conditions. 2011;6:20-31. Russian.
  4. Frances E. L., Jonathan M., Patrick A.S. [The µ-Opioid Receptor in Cancer Progression Is There a Direct Effect?] Anesthesiology. 2012;116:940 –945.
  5. 5. Mathew B, et al. [The novel role of the mu opioid receptor in lung cancer progression: a laboratory investigation]. Anesth Analg. 2011;112(3):558-567.
  6. 6. Shavit, Y., Lewis, J.W., Terman, G.W. [Opioid peptides mediate the suppressive effect of stress on natural killer cell cytotoxicity]. Science. 1984;223:188-190.
  7. Cata J.P., Gottumukkala V., Thakar D., Keerty D., Gebhardt R., Liu D.D. [Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall celllung cancer]. J Clin Anesth. 2014; Feb;26(1):3-17.
  8. Rodgers A., Walker N., Schug S. [Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials]. British Journal of Anaesthesia. 2000; 321:1493.
  9. [Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management]. Anesthesiology. 2012; 116(2):248-73.
  10. Werner M.U., Soholm L., Rotboll-Nielsen P., Kehlet H. [Does an acute pain service improve postoperative outcome]. Anesthesia & Analgesia. 2002; 95:1361-1372.

11. Magdalena D., Georgescu C.C., Tantu M. [Methods of postoperative analgesia – administration of epidural bupivacaine in patients with colon cancer undergoing surgery]. Current Health Sciences Journal. 2013; Vol.39(1):35-38.

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