Effizienz der onkologischen Chirurgie

Efficacy of oncologic surgery. Does anesthesia influence postoperative outcome?

Summary

Major surgical interventions in tumour surgery are still associated with perioperative cardiopulmonary, infectious, thromboembolic, cerebral, and gastrointestinal complications. There are different prophylactic and therapeutic possibilities to anticipate or counteract these perioperative complications. The most important, including beta blockers and alpha-2-agonists for patients at coronary risk, preoperative optimisation of oxygen transport in high risk surgical patients and the concept of multimodal perioperative therapy (analgesia, early mobilisation, early enteral nutrition, and others) combined with high perioperative inspiratory oxygen concentration and maintenance of normothermia to reduce wound infection and cardiac complications are described in this paper.

Zusammenfassung

Große onkologische Operationen können zu unerwünschten Folgeerscheinungen wie kardiopulmonalen, infektiösen oder thromboembolischen Komplikationen, zerebraler Dysfunktion, Erbrechen und gastrointestinaler Paralyse führen. In der vorliegenden Übersicht werden wichtige und moderne prophylaktische und therapeutische Strategien vorgestellt, diesen Komplikationen entgegenzuwirken: die perioperative Gabe von Betablockern oder Alpha-2-Agonisten für koronare Risikopatienten, die präoperative Optimierung von Risikopatienten durch Steigerung des Sauerstoffangebots vor dem chirurgischen Eingriff, das Konzept der multimodalen perioperativen Therapie (Analgesie, frühe Mobilisierung, frühe enterale Ernährung und andere) in Kombination mit der intra- und postoperativen Gabe erhöhter Sauerstoffkonzentrationen sowie die Aufrechterhaltung einer Normothermie zur Reduktion von Wundinfektionen und kardialen Komplikationen.

Key words

High risk surgery - beta blocker - alpha-2-agonists - coronary risk - preoperative optimisation - multimodal analgesia

Schlüsselwörter

Hochrisikochirurgie - Betablocker - Alpha-2-Agonisten - kardiales Risiko - präoperative Optimierung - multimodale Analgesie

Literatur

• 1 Akca O, Melischek M, Scheck T, Hellwagner K, Arkilic C F, Kurz A, Kapral S, Heinz T, Lackner F X, Sessler D I. Postoperative pain and subcutaneous oxygen tension.  Lancet. 1999;  354 41-42
• 2 Badner N H, Knill R L, Brown J E, Novick T V, Gelb A W. Myocardial infarction after noncardiac surgery.  Anesthesiology. 1998;  88 572-578
• 3 Berendes E, Möllhoff T, Van Aken H, Schmidt C, Erren M, Deng M C, Weyand M, Loick H M. Effects of dopexamine on creatinine clearance, systemic inflammation, and splanchnic oxygenation in patients undergoing coronary artery bypass grafting.  Anesth Analg. 1997;  84 950-957
• 4 Berlauk J F, Abrams J H, Gilmour I J, O'Connor S R, Knighton D R, Cerra F B. Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized clinical trial.  Ann Surg. 1991;  214 289-297
• 5 Bishop M H, Shoemaker W C, Appel P L, Meade P, Ordog G J, Wasserberger J, Wo C J, Rimle D A, Kram H B, Umali R. et al . Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma.  J Trauma. 1995;  38 780-787
• 6 Bland R, Shoemaker W C, Shabot M M. Physiologic monitoring goals for the critically ill patient.  Surg Gynecol Obstet. 1978;  147 833-841
• 7 Böttiger B W, Martin E. Prävention perioperativer Myokardischämien - ein Update.  Anaesthesist. 2000;  49 174-186
• 8 Boyd O, Grounds R M, Bennett E D. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients.  JAMA. 1993;  270 2699-2707
• 9 Brodner G, Mertes N, Van Aken H, Möllhoff T, Zahl M, Wirtz S, Marcus M A, Buerkle H. What concentration of sufentanil should be combined with ropivacaine 0.2 % wt/vol for postoperative patient-controlled epidural analgesia?.  Anesth Analg. 2000;  90 649-657
• 10 Brodner G, Mertes N, Van Aken H, Pogatzki E, Buerkle H, Marcus M A, Möllhoff T. Epidural analgesia with local anesthetics after abdominal surgery: earlier motor recovery with 0.2 % ropivacaine than 0.175 % bupivacaine.  Anesth Analg. 1999;  88 128-133
• 11 Brodner G, Pogatzki E, Van Aken H, Buerkle H, Goeters C, Schulzki C, Nottberg H, Mertes N. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy.  Anesth Analg. 1998;  86 228-234
• 12 Flancbaum L, Ziegler D W, Choban P S. Preoperative intensive care unit admission and hemodynamic monitoring in patients scheduled for major elective noncardiac surgery: a retrospective review of 95 patients.  J Cardiothorac Vasc Anesth. 1998;  12 3-9
• 13 Frank S M, Fleisher L A, Breslow M J, Higgins M S, Olson K F, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial.  JAMA. 1997;  277 1127-1134
• 14 Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO₂ Collaborative Group.  N Engl J Med. 1995;  333 1025-1032
• 15 Greif R, Akca O, Horn E P, Kurz A, Sessler D I. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group.  N Engl J Med. 2000;  342 161-167
• 16 Hayes M A, Timmins A C, Yau E H, Palazzo M, Hinds C J, Watson D. Elevation of systemic oxygen delivery in the treatment of critically ill patients.  N Engl J Med. 1994;  330 1717-1722
• 17 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.  Br J Anaesth. 1997;  78 606-617
• 18 Kehlet H, Dahl J B. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment.  Anesth Analg. 1993;  77 1048-1056
• 19 Kurz A, Sessler D I, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.  N Engl J Med. 1996;  334 1209-1215
• 20 Liu S, Carpenter R L, Neal J M. Epidural anesthesia and analgesia. Their role in postoperative outcome.  Anesthesiology. 1995;  82 1474-1506
• 21 Mangano D T. Adverse outcomes after surgery in the year 2001 - a continuing odyssey.  Anesthesiology. 1998;  88 561-564
• 22 Mangano D T, Browner W S, Hollenberg M, Li J, Tateo I M. Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group.  JAMA. 1992;  268 233-239
• 23 Mangano D T, Layug E L, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group.  N Engl J Med. 1996;  335 1713-1720
• 24 Möllhoff T, Loick H M, Van Aken H, Schmidt C, Rolf N, Tjan T D, Asfour B, Berendes E. Milrinone modulates endotoxemia, systemic inflammation, and subsequent acute phase response after cardiopulmonary bypass (CPB).  Anesthesiology. 1999;  90 72-80
• 25 Möllhoff T, Rolf N. Anesthesiologic management of cardiac “at-risk” patients.  Anästhesiol Intensivmed Notfallmed Schmerzther. 1997;  32 739-743
• 26 Mythen M G, Webb A R. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery.  Arch Surg. 1995;  130 423-429
• 27 Oliver M F, Goldman L, Julian D G, Holme I. Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT).  Anesthesiology. 1999;  91 951-961
• 28 Page G G, Ben-Eliyahu S, Yirmiya R, Liebeskind J C. Morphine attenuates surgery-induced enhancement of metastatic colonization in rats.  Pain. 1993;  54 21-28
• 29 Page G G, McDonald J S, Ben-Eliyahu S. Pre-operative versus postoperative administration of morphine: impact on the neuroendocrine, behavioural, and metastatic-enhancing effects of surgery.  Br J Anaesth. 1998;  81 216-223
• 30 Poldermans D, Boersma E, Bax J J, Thomson I R, van de Ven L L, Blankensteijn J D, Baars H F, Yo T I, Trocino G, Vigna C, Roelandt J R, van Urk H. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group.  N Engl J Med. 1999;  341 1789-1794
• 31 Sessler D I, Kurz A, Lenhardt R. Re: Hypothermia reduces resistance to surgical wound infections.  Am Surg. 1999;  65 1193-1196
• 32 Shoemaker W C, Appel P L, Kram H B. Hemodynamic and oxygen transport responses in survivors and nonsurvivors of high-risk surgery.  Crit Care Med. 1993;  21 977-990
• 33 Shoemaker W C, Appel P L, Kram H B, Waxman K, Lee T S. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.  Chest. 1988;  94 1176-1186
• 34 Shoemaker W C, Wo C C, Thangathurai D, Velmahos G, Belzberg H, Asensio J A, Demetriades D. Hemodynamic patterns of survivors and nonsurvivors during high risk elective surgical operations.  World J Surg. 1999;  23 1264-1270
• 35 Tuchschmidt J, Fried J, Astiz M, Rackow E. Elevation of cardiac output and oxygen delivery improves outcome in septic shock.  Chest. 1992;  102 216-220
• 36 Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.  BMJ. 1999;  318 1099-1103