Svälta’eller’göda’inför’planerad’ kirurgi?h24-files.s3.amazonaws.com/40035/956463-M5jlg.pdfTruong!A!etal.!! WorldJ Gastrointest!Surg!2016’May’27;’8(5):’353C362’’

Svälta eller göda inför planerad kirurgi?

Mikael Wirén [email protected]

Agenda

•  Nutri>onsbedömning •  Preopera>v viktnedgång •  Preopera>vt nutri>onsstöd •  Pre-‐op kolhydratuppladdning •  Preopera>v lågkaloridiet

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Varför?

H.O Studley, JAMA 1936, 106, 458

28 cases – 1 death 3.5%

18 cases – 6 deaths 33.3%

20%

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Impact of malnutri>on on gastrointes>nal surgical pa>ents. Mosquera C et al. J Surg Res 2016;95-‐101

•  N=490, mean age 64 y, 50,6 % females •  Major elec>ve GI-‐surgery •  19% moderately or severely malnourished •  Malnutri>on worsens length of stay (OR=1,67) •  Malnutri>on worsens costs (OR=2,49) •  No significant differences in complica>ons, mortality or readmission rates.

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Generella problem vid GI-‐kirurgi

Infection - MOF

Anxiety Pain

Nausea

Vomiting

Fluid balance disturbancies Lack of healing

Anastomotic leakage

Tissue contamination

Malnutrition

Cardio-respiratory complications

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När?

Trauma Trauma

Trauma Respons

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VÄRLDENS FÖRSTA PUBLICERADE RANDOMISERADE STUDIE

Studiedesign •  1747 ankom Salisbury med 12 sjömän med symptom på

skörbjugg. Alla bodde under samma förhållanden och fick samma kost.

•  Men dessutom erhöll de något av de sex olika kosbllskoc

som Lind ville undersöka; cider, vitriolelixir, vinäger, havsvacen, havrevacen eller cirtusfrukter.

•  Det visade sig övertygande ac behandlingen med

citrusfrukter var bäst -‐ de pa>enterna var helt arbetsföra efer 6 dagar. Näst bäst var cider -‐ de männen var på bäcringsvägen då försöket avbröts efer gorton dagar. Alla de övriga >llskocen var helt utan effekt.

•  Metabolism •  Protein catabolism •  Immunological function •  Scavenger functions

Malnutrition Disease Trauma Tumour

Surgery Drugs

Antibiotics Nutrition

Growth factors

Mortality Morbidity

Body composition Serum proteins

Immun parameters Molecular biology

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Sjukdomsrelaterad malnutri>on

•  Kronisk inflamma>on •  Infek>on •  Malignitet •  Efer trauma – Kirurgisk behandling

•  Läkemedelseffekter •  Psykiatrisk sjukdom

Nutri>on and abdominal surgery

•  Obstruc>ng upper GI diseases – Malignancies – Func>onal diseases

•  Dysfunc>on of the lower GI tract –  Inflammatory bowel disease – Short bowel

•  Malnutri>on + major surgery

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Malignant obstruc>on

•  Esofageal cancer •  Gastric cancer •  Duodenal/pancrea>c-‐cancer

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Malignancy and malnutri>on

•  Pankrea>c cancer •  Liver cancer •  Peritoneal carcinomatosis

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Benign obstruc>ons

•  Esofagus – Diver>culum – Esofagi>s – Stricture

•  Stomach – Stenosis afer ulcer – Stenosis afer surgery (BI, BII, Roux-‐Y)

•  Duodenum – Malrota>on (Ladd´s band)

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Dysfunc>on of upper GI-‐tract

•  Esofagus – Achalasia – Mo>lity disorders

•  Stomach – Gastric paresis (DM)

•  Small intes>ne – Pseudoobstruc>on

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TREATMENT Parenteral and enteral op>ons

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Nya koncept

•  Tidig enteral nutri>on •  Immunonutri>on •  Tillväxpaktorer och specifika nutrienter – Glutamin

•  Pre-‐opera>v kolhydratuppladdning •  Blodsockerkontroll •  Natrium och vätskerestrik>on

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How much to give?

�  Fluid 30 ml/kg �  Adequate urinary output

�  Energy �  25-‐30 kcal/kg

�  Protein �  0,15-‐0,3 g N/kg = 1-‐2 g protein/kg (1 g N= 6,25 g protein=25 g muskel)

�  Sodium and Potassium �  Basal requirements + losses

�  Indirect calorimetry

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When to use parenteral nutri>on?

•  When the GI-‐tract cannot be used – High output intes>nal fistulas – Severe pancrea>>s – Short bowel – Pseudoobstruc>on

•  In addi>on to enteral nutri>on

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Agenda -‐preopera>v nutri>on

•  Varför? •  Vid vilken typ av kirurgi? – Övre eller kolorektal?

•  När? – Vad har högst prioritet?

•  Hur? – Oralt, enteralt, parenteralt?

•  Evidens? 17-‐05-‐11 Kirub 17 20

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Albumin

•  Albumin is a single polypep>de responsible for five main func>ons:

•  (1) maintenance of colloid osmo>c pressure; •  (2) binding and transport of solutes; •  (3) free radical scavenging; •  (4) platelet func>on inhibi>on and an>thrombo>c effect;

•  (5) beneficial effects on vascular permeability in the sebng of shock and sepsis[1].

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Truong A et al.

World J Gastrointest Surg 2016 May 27; 8(5): 353-‐362

•  Although albumin remains a flawed marker of nutri>on, it offers clear prognos>c value in predic>ng pa>ent outcomes afer colorectal surgery.

•  Hypoalbuminemia significantly influences the length of hospital stay and complica>on rates, specifically surgical site infec>on, enterocutaneous fistula, and DVT forma>on.

•  Although clinical hypoalbuminemia is classically defined as serum concentra>ons < 3.0 g/dL, clinical judgment must account for albumin levels ≤ 3.4 g/dL as even modest hypoalbuminemia can affect outcomes.

•  Surgical delay for preopera>ve nutri>on has been shown to improve the morbidity and mortality in pa>ents with severe nutri>onal risk.

•  Hypoalbuminemic pa>ents may benefit from a staged colorectal resec>on vs a single opera>on, especially in the sebng of IBD.

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HÖGRISKPATIENTER INOM ÖVRE GI

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Pre-‐op evalua>on in high risk pa>ents

•  Inhospital mortality in Europe = 3-‐4% •  Morbidity increases with BMI but not mortality in the ICU

•  Satura>on < 92! •  Male, BMI>50, age>50, CV disease… •  Opioid free anaesthesia

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CMAJ. 2011 October 4; 183(14): e1059–e1066. Using the Edmonton obesity staging system to predict mortality in a populaDon-‐representaDve cohort of people with overweight and obesity Raj S. Padwal, MSc MD, Nicholas M. Pajewski, PhD, David B. Allison, PhD, and Arya M. Sharma, MD PhD

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VILKEN BETYDELSE HAR KIRURGISK TEKNIK?

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Surgical Skill and ComplicaDon Rates aPer Bariatric Surgery John D. Birkmeyer, M.D et al. for the Michigan Bariatric Surgery Collabora>ve

N Engl J Med 2013; 369:1434-‐1442

•  Mean summary ra>ngs of technical skill ranged from 2.6 to 4.8 across the 20 surgeons.

•  The bocom quar>le of surgical skill, as compared with the top quar>le, was associated with higher complica>on rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01).

•  The lowest quar>le of skill was also associated with longer opera>ons (137 minutes vs. 98 minutes, P<0.001) and higher rates of reopera>on (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001).

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Who is important? “The most important person in the opera>ng room is the pa>ent.” — Russell John Howard (1875–1942) “The most important result of any surgical opera>on is a live pa>ent.” — Charles H. Mayo (1865–1939) “It is becer if the pa>ent goes to the plas>c surgeon afer an opera>on, with a large scar, than to the pathologist with a small one.” — Denis M. Arkhipov

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KAN MAN SVÄLTA PATIENTER FÖRE OPERATION?

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Arch Surg. 2011 Nov;146(11):1300-‐5

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Arch Surg. 2011 Nov;146(11):1300-‐5

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Arch Surg. 2011 Nov;146(11):1300-‐5

LÖNAR SIG PREOPERATIV KOLHYDRATUPPLADDNING?

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GASTROINTESTINALKANALENS ANATOMI, EMBRYOLOGI OCH FYSIOLOGI

Vi börjar med det basala…

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Nutri>on, intes>nal barrier and liver func>on

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GALT Kupfer cell dysfunction

Liver Steatosis

Cholestasis

Intestine Permeability

sIgA BTL

Enteral nutrition not possible

Total parenteral nutrition

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Fallbeskrivningar

Korcarmsyndrom Sviktande tarm

Female born 1962

•  2010 Gastric bypass •  Aug 2012 Internal hernia>on, intes>nal ischemia

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Female born 1962

•  2010 Gastric bypass •  Aug 2012 Internal hernia>on, intes>nal ischemia

•  Arrival Open abdomen, ven>lator and dialysis

•  September Small bowel resec>on 150 cm •  September Anastomo>c leakage, diversion of alimentary and biliopancrea>c limb

•  October Going home afer 6 weeks 17-‐05-‐11 Kirub 17 45

Treatment op>ons?

•  55 kg, 168 cm •  Albumin 15 •  Normal liver func>on •  Normal renal func>on •  Leucocyte count and CRP normal

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Treatment at home

•  TPN Olive oil based, 31 kcal/kg •  Addex NaCl 20ml, •  PPI •  LMWH •  Durogesic •  An>fungal therapy

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Male born 1964

•  1996 renal transplant (Chronic glomerulonephri>s)

•  2005 GI bleeding •  Burkics lymfoma (small bowel) •  Chemotherapy •  Small bowel perfora>on, resec>on and proximal jejunostomy

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What to do?

•  Ongoing chemotherapy •  Recurrent neutropenia •  Severe sep>c episodes •  High output fistula •  Progressive liver dysfunc>on due to TPN?

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Paradigmskife

ü  Preopera>v fasta ü  Sond, dränage ü  Tarmvila postopera>vt ü  Tarmrengöring ü  Smärtlindring vid behov ü  Klara vätskor ”enl. lista” ü  Svängande blsr är

naturligt post-‐op

Ø  Fri dryck, uppladdning Ø Minimera sond/drän Ø  Använd tarmen >digt Ø  Probio>ka Ø  Planerad analgesi Ø  Undvik övervätskning Ø  Normalisera blsr Ø  Kombinera PN/EN

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Take home

•  Ingen pa>ent ska försämras under pågående utredning inför kura>v behandling

•  En veckas nutri>onsstöd kan förbäcra funk>on men inte kroppskomposi>on

•  Preop kolhydratuppladdning kan vara av värde vid stor GI-‐kirurgi

•  Friska obesa minskar levervolymen med LCD. •  Sjuka obesa pa>enter ska nutrieras fullt ut.

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BRA NUTRITION RÄDDAR INTE DÅLIG KIRURGI MEN BRA KIRURGI KAN MISSLYCKAS OM LÄKNINGEN KOMPROMETTERAS

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Documents

Svälta’eller’göda’inför’planerad’ kirurgi?h24-files.s3.amazonaws.com/40035/956463-M5jlg.pdfTruong!A!etal.!! WorldJ Gastrointest!Surg!2016’May’27;’8(5):’353C362’’