Genel | Kongre ve Bilimsel Toplantılar

Informing the Patient

A patient who does not know what will happen will definitely experience anxiety. Therefore, the patient should be informed verbally and in writing at the first meeting. This meeting should include details about what the patient will experience during the hospital stay and, if possible, should be conducted by the surgeon, anesthesiologist and nurse. Concepts such as preoperative preparation, pain, oral intake and early mobilization should be explained to the patient. The important point here is not only informing the patient passively, but also explaining the role he/she will assume throughout the process. In this way, the patient will take an active role and will experience less anxiety, which is an important determinant of well-being.

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Preoperative Bowel Cleansing

Preoperative bowel cleansing: Bowel preparation practices have been traditionally practiced before colon surgery for many years. However, meta-analyses published recently have shown that bowel cleansing before colon surgery does not prevent anastomotic leaks, on the contrary, it significantly increases this risk and causes serious fluid electrolyte imbalances, especially in elderly patients. Therefore, bowel cleansing should not be performed except in patients scheduled for intraoperative colonoscopy. Further studies are needed to determine the optimum routine for very low rectal anastomosis. However, if a diverting ostomy is to be created to protect the anastomosis, the distal bowel should be cleaned. Bowel cleansing is contraindicated in major surgeries other than colon surgery.

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Oral Carbohydrate Loading Instead of Preoperative Fasting

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Preoperative Nutrition

The nutritional status of every patient who will undergo elective major surgery must be evaluated. Although many different methods can be used in this evaluation, the most recommended ones are the subjective global assessment (SGA) and NRS-2002. Body mass index can also provide information about nutritional status. Preoperative nutritional support planning should be made for patients with SGA-C or NRS-2002 scores above 3. This planning should be organized by teams working on clinical nutrition and the surgery should be postponed for a certain period of time (usually 7-10 days is sufficient).

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Preoperative Optimization

Many developments have been made in preoperative cardiopulmonary preparation in the last 30 years and as a result, mortality rates have been reduced. However, the same success has not been achieved in complication rates due to reasons such as obesity, diabetes, modern lifestyle, hypertension and old age. In order to achieve success in this sense, all patients who will undergo major surgery should undergo surgery after their general condition has been brought to the highest level. In recent years, the concept of postoperative rehabilitation has been replaced by preoperative prehabilitation. The patient should undergo surgery after preparations that include quitting smoking and alcohol 8 weeks before the surgery, exercise programs, reducing the risk of comorbidities by making necessary consultations and many other similar issues.

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Premedication

Side effects of long-acting premedications such as opioids, long-acting sedatives and hypnotics prevent recovery by causing a prolongation of hospital stay. In contrast, short-acting anxiolytics do not prolong recovery or hospital stay. Therefore, unnecessary premedication should be avoided before anesthesia. Only patients who have previously used such medications can continue their medications with psychiatric consultation.

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Thromboembolism Prophylaxis

Meta-analyses have shown that subcutaneous low-dose unfractionated heparin regimens are effective in reducing deep vein thrombosis, pulmonary embolism, and mortality in patients undergoing colorectal surgery. Meta-analyses comparing low molecular weight heparin (LMWH) with unfractionated heparin have found no difference in efficacy or bleeding risk. LMWH is preferred because of its once-daily dosage and lower risk of heparin-induced thrombocytopenia. Antiplatelet drugs and intravenous dextran are less effective for prophylaxis of deep vein thrombosis, but may be effective in preventing pulmonary embolism. Due to their side effect profiles, they can only be recommended for high-risk patients in whom LMWH and unfractionated heparin are contraindicated. There is insufficient evidence on the safety of continuous epidural analgesia in patients receiving LMWH. Prophylactic doses of LMWH should be given before ion of an epidural catheter and within 12 hours after its removal. Although the concomitant use of NSAIDs and LMWH is considered safe, a potential risk of epidural hematoma has been mentioned. Attention should be paid to other factors affecting coagulation and, where necessary, alternative methods of thromboprophylaxis (antithromboembolism stockings, etc.) should be used.

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Antimicrobial Prophylaxis

Antibiotic prophylaxis should be administered in accordance with local and universal guidelines and before skin incision. Although a single dose is sufficient, it is recommended to repeat intraoperatively in surgeries lasting longer than 3 hours. New generations of antibiotics should not be used for prophylaxis and should be reserved for infectious complications.

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Anesthesia Protocol

Although there is no definitive information on the most appropriate anesthesia method for the surgical procedure to be performed, the use of short-acting agents seems rational. It is logical to use short-acting agents (propofol, remifentanil hydrochloride) instead of long-acting intravenous opioids (morphine sulfate, morphine hydrochloride, fentanyl citrate), thus allowing proactive recovery to begin immediately after surgery. Midthoracic epidural anesthesia, which is strongly recommended in colon surgeries, will have two benefits. The first is to provide adequate analgesia with lower postoperative morbidity. The second is that midthoracic epidural blockade will also block the adrenal glands, thus reducing the metabolic endocrine response to trauma. Thus, the release of stress hormones will be reduced, the duration of postoperative ileus will be shortened, and postoperative insulin resistance will decrease. As a result, the severity of metabolic trauma experienced by the patient will be reduced, their well-being will be increased, and the duration of hospital stay will be reduced. Although the risk of hematoma, abscess, or neurologic damage due to epidural anesthesia is between 0.01% and 0.6%, this possibility should definitely be considered. The optimal T elevation for colon surgery is between 6 and 11% to provide ideal anesthesia and analgesia. The catheter should be placed while the patient is awake to avoid neurologic complications. Intraoperative blockade can be achieved by continuous infusion of local anesthetic (e.g., 0.1% to 0.25% bupivacaine hydrochloride, or 0.2% ropivacaine hydrochloride) and an additional low opiate dose (e.g., 2.0-μg/mL fentanyl citrate or 0.5 to 1.0-μg/mL sufentanil citrate) at 4 to 10 mL/h. Small doses of epidural opioids act synergistically with epidural local anesthetics in providing analgesia. Addition of epinephrine (1.5 - 2.0μg/mL) to thoracic epidural infusion increases analgesia. In conclusion, the recommended protocol is to perform the surgery with midthoracic epidural blockade and short-acting anesthetics, and to provide analgesia via midthoracic epidural catheter in the postoperative period.

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Selection of Surgical Incisions

There are studies reporting that transverse or curved incisions used in abdominal surgery are more advantageous than longitudinal incisions in terms of postoperative pain and pulmonary dysfunction. However, many surgeons prefer longitudinal incisions due to their exploration advantages. According to ERAS protocols, although there is no binding element regarding the shape of the incision, the shortest possible incision should be used.

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Nasogastric Tube Use

A meta-analysis conducted 22 years ago showed that routine nasogastric decompression should be avoided after colorectal surgery, as patients without a nasogastric tube had less fever, atelectasis, and pneumonia. A recent Cochrane meta-analysis of 33 studies including over 5000 patients confirmed this, and also emphasized that patients' bowel function returned earlier when nasogastric decompression was avoided. Having a nasogastric tube also delays oral feeding.

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Prevention of Intraoperative Hypothermia

Hypothermia may increase bleeding by stimulating sympathetic discharge and metabolic endocrine response to trauma and by disrupting coagulation systems. Some studies have shown that maintaining normothermia using a warming blanket reduces wound infections, cardiac complications, bleeding, and transfusion requirements. Starting systemic warming preoperatively, continuing it during surgery, and extending it up to 2 hours postoperatively may provide additional benefits.

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Multimodal Management of Postoperative Nausea and Vomiting

Postoperative nausea and vomiting should be prevented as they will also restrict the patient's oral intake in the early period. In addition to the use of antiemetics for this purpose, the use of agents that induce vomiting, especially during surgery, should be avoided. Risk factors for postoperative nausea and vomiting are being a woman, not smoking, a history of motion sickness (or postoperative nausea, vomiting anemia), and postoperative opioid administration. Patients at moderate risk (factor 2) should receive prophylaxis with dexamethasone sodium phosphate at the beginning or a serotonin receptor antagonist at the end of the operation. Patients at high risk (factor 3) should receive general anesthesia with propofol and remifentanil, supplemented with 4-8 mg dexamethasone sodium phosphate at the beginning of the operation, serotonin receptor antagonists or droperidol or 25-50 mg metoclopramide hydrochloride 30-60 minutes before the end of the operation.

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Perioperative Fluid Management

With traditional perioperative intravenous fluid regimens in abdominal surgery, patients may receive 3.5 to 7 L of fluid on the day of surgery and more than 3 L for the following 3 to 4 days. This may result in a weight gain of 3 to 6 kg. These practices may delay the return of normal gastrointestinal function, impair wound and anastomosis healing, and affect tissue oxygenation. This results in a long hospital stay. Evidence from recent studies indicates that overloading and restricting fluid intake significantly reduce postoperative complications and shorten the length of hospital stay, and therefore should be recommended. In the modern understanding of fluid therapy, fluid infusion that does not leave the patient dehydrated is considered sufficient. The best way to limit postoperative intravenous fluid administration is to stop intravenous infusions early and start oral fluids immediately. The target here should be the first day after surgery. Accordingly, oral fluids should be given to the patient after 2 hours postoperatively and at least 800 ml should be taken on the day of surgery. As oral fluid intake increases, the amount of parenteral fluid should be reduced. Intraoperatively and in the early postoperative period, it is recommended to use vasopressor agents instead of fluids, especially in combating hypotension that may develop due to epidural blockade. Transesophageal Doppler ultrasonography may be an appropriate guide for measuring cardiac output and providing hydration in high-risk patients.

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Abdominal Drains

There is no current study showing the positive contribution of drain use to surgical outcomes in elective abdominal surgery. In addition, the presence of a drain reduces patient mobilization and it has been shown that drain use has no effect on anastomotic leaks. For these reasons, routine use of drains should be avoided. Guidelines for other system surgeries also include recommendations that limit the unnecessary use of drains.

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Urinary Catheters

Bladder catheters should be removed early due to their disadvantages such as urinary infection and restriction of mobilization. However, since the possibility of urinary retention increases as a result of epidural blockage, the catheter should be kept as long as the blockage continues. In surgeries with extensive pelvic dissection, suprapubic catheterization should be preferred over urinary catheters.

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Glucose Level Management

When ERAS protocols are applied, blood glucose levels can be managed more easily. Since both metabolic stress and postoperative insulin resistance are minimized with many elements, very few patients experience difficult-to-control hyperglycemia. Diabetic patients should be well prepared preoperatively and closely monitored postoperatively. As recommended in many guidelines, the goal should be to keep blood sugar levels around 140-180 mg/dL.

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Stimulation of Gastrointestinal Motility

Abdominal cerrahiden sonra geç taburcu olmanın temel nedeni olan postoperatif ileusun önlenmesi ERAS protokollerinin esas amacıdır. Postoperatif ileusun azaltılması veya tedavi edilmesinde şu anda hiçbir prokinetik ajan etkili olmamasına karşın, birçok başka müdahale başarılı olmuştur. Midtorasik epidural analjezi, intravenöz opioid analjeziyle kıyaslandığında, postoperatif motilite bozukluğunun önlenmesinde oldukça etkilidir. Ameliyat sırasında ve sonrasında aşırı sıvı yüklemesi gastrointestinal fonksiyonu bozmaktadır, bundan kaçınılmalıdır. Postoperatif erken dönemde gastrointestinal motilitenin uyarılması ve belki daha da önemlisi motiliteyi olumsuz etkileyecek ajanların kullanılmaması erken enteral beslenmenin sağlanabilmesi için şarttır. Bu amaçla epidural analjezi, opiadlardan ve aşırı hidrasyondan kaçınılması ve 2x1 gr/gün oral magnezyum oksid kullanılması gerekmektedir. Ayrıca, açık cerrahi ile kıyaslandığında laparoskopik yapılan ameliyatlarda barsak fonksiyonu daha erken geri döner ve oral diyet alımı daha hızlı bir şekilde sağlanır.

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Postoperatif analjezi

Meta-analizler, hem açık hem de laparoskopik cerrahide ameliyattan sonraki 2 - 3 gün boyunca opioidler ile veya sürekli epidural lokal anestezik ile optimum analjezi sağlandığını göstermiştir. İntravenöz opioidler verildiğinde, aynı etkinlikte analjezi sağlamamaktadır ve epidural lokal anestezik tekniklere kıyasla cerrahi stres yanıtı üzerine daha düşük düzeyde faydalı etkiye sahiptir. Epidural blokajın uygulanmasından sonra splanknik sahanın perfüzyonu, kardiyak debide ve ortalama arteriyel basınçta bazı değişiklikler olmaktadır. Bu nedenle, kan basıncını dengelemek üzere vazopressörler düşünülmelidir. Kalp yetmezliği durumunda, kolon kan akımını iyileştirmek için yeterli bir prelod gerekir ki bunun için pozitif inotroplar zorunludur. Düşük doz noradrenalin ve dobutamin hidroklorür splanknik sahanın perfüzyonu için zararlı değildir. Ameliyattan sonraki ilk iki gün epidural kateter yoluyla devamlı analjezik infüzyonu ve buna ek olarak 4mg/gün parasetamol rutin olarak kullanılmalıdır. Eğer bu protokol yetersiz kalırsa aralarda nonsteroid antiinflamatuvar ilaçlar eklenebilir. Epidural kateterin çekilmesine yakın dönemde rutin analjezik olarak nonsteroid antiinflamatuvar ilaçlar başlanmalı ve taburcu olduktan sonra da ihtiyaç halinde kullanılmalıdır.

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Postoperatif beslenme

Erken enteral veya oral beslenme ile konservatif oral gıda alımını karşılaştıran randomize kontrollü çalışmalar, elektif gastrointestinal rezeksiyondan sonra hastaları aç tutmanın hiçbir avantajı olmadığı sonucuna varmaktadır. Erken besleme hem enfeksiyon riskini hem de hastanede kalma süresini azaltmıştır ve yüksek bir anastomoz kaçağı riski oluşturmamıştır. Ancak, erken beslenen hastalarda kusma riski artmıştır ve multimodal motilite tedavisi eklenmediğinde, şişkinlik, pulmoner fonksiyonda bozukluk ve mobilizasyonda gecikme gibi sorunlar görülmüştür. Hastalar ameliyattan sonraki ikinci saatte oral sıvı, dördüncü saatte katı gıda almaya teşvik edilmelidir. Yeterli oral beslenme sağlanıncaya kadar oral nütrisyon solüsyonlarıyla destek verilmelidir. Beslenme durumunda bozukluk nedeniyle preoperatif nütrisyon desteği verilen hastalarda (özellikle kanserli hastalarda) ameliyat sonrası destek en az 8 hafta devam etmelidir. ERAS programlarında, ideal enerji ve protein alımına erişmek üzere oral beslenme ürünleri operasyondan önceki gün ve operasyondan sonraki en az ilk 4 gün boyunca başarılı bir şekilde kullanılmıştır. Kombinasyon halinde kullanıldığında preoperatif oral karbonhidrat yüklemesi, epidural analjezi ve erken enteral beslenmenin, hiperglisemiye neden olmadan uygun nitrojen dengesi sağladığı gösterilmiştir.

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Erken mobilizasyon

Ameliyat sonrası yatak istirahatı uzadıkça insülin rezistansı artar, kaslarda zayıflama ve kas kütlesi kaybı gelişir. Bunun yanı sıra pulmoner fonksiyonlarda bozukluk olur ve tromboemboli riski artar. Epidural analjezi birçok açıdan önemli olduğu gibi erken mobilizasyonda da kilit rol oynamaktadır. Hastanın ağrısının kesilip hareket edebileceği fiziksel şartların sağlanması hedeflenmelidir. ERAS protokolüne göre, hastanın ameliyat günü 2 saat, takip eden günlerde ise taburcu olana kadar günde 6 saat yatak dışında kalması sağlanmalıdır.

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Hastaneden çıkış

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Takip

Eve gönderilen hastalar 24 – 48 saat sonra telefon ile aranmalı ve durumları öğrenilmelidir. Herhangi bir sorun yaşanmazsa, postoperatif 7 – 10. günlerde yaranın kontrolü ve dikişlerin alınması için davet edilmelidir. Bu dönemde patoloji raporu da hazırlanmış olacağından, gerekiyorsa ilave onkolojik tedavi planlanmalıdır. Eve çıkarılan hastaların %1 – 3‘ünde anastomoz kaçağı veya başka bir majör komplikasyon gelişeceği aklıda tutulmalı ve her şikayet mutlaka dikkatle incelenmelidir. Sonraki görüşme postoperatif 30. gün telefon ile yapılabilir. 

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Sonuçların denetimi

Klinik sonucu belirlemek ve protokolün başarılı şekilde uygulanmasını sağlamak için sistemik bir denetim zorunludur. Sonuçlar istenen kalite standartlarına erişemezse, başarısız uygulama ile uygulanan protokolden istenen etkinin elde edilmemesi arasında ayırım yapmak önemlidir. Benzer protokoller ve aynı kayıt yöntemlerini kullanan başka merkezlerle karşılaştırma yapmak gerekmektedir.

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