Акушерство и Гинекология Санкт-Петербурга. 2017; : 70-75
Опыт применения программ ускоренной послеоперационной реабилитации у гинекологических больных
Аннотация
Цель: провести оценку эффективности применения протоколов ускоренной постоперационной реабилитации у больных гинекологического профиля.
Материал и методы. С 2012 года в «Швейцарской университетской клинике» были внедрены протоколы ускоренной послеоперационной реабилитации хирургических, колопроктологических и гинекологических пациентов. По программе ускоренной реабилитации за 2012–2015 гг. прошли лечение 975 пациенток с миомой матки, 198 пациенток с эндометриозом и 19 пациенток с раком тела матки, всего 1192. Для каждого из них составлялся индивидуальный план, все элементы которого отмечались в специальной карточке. Протокол для гинекологических пациентов отличался от общехирургического тем, что в него был включен пункт о гипоэстрогенных нарушениях после операции.
Результаты. При сравнении раннего послеоперационного периода после fast-track было отмечено, что при традиционном ведении пациенток нарушение моторно-эвакуаторной функции кишечника развивалось в 5 раз чаще (8% против 1,6% прооперированных больных), послеоперационная рвота имела место в 6 раз чаще (12,2% против 2%), а потребность в обезболивании опиоидными анальгетиками была на 34% выше. Повторная госпитализация потребовалась трем пациенткам. Повторных вхождений в брюшную полость не потребовалось ни у одной из пациенток.
Заключение. Применение протокола ускоренной реабилитации у больных гинекологического профиля позволяет улучшить течение раннего послеоперационного периода, уменьшить постоперационный болевой синдром и риск пареза кишечника, а также сократить сроки реабилитации.
Список литературы
1. Agnelli G., Bolis G., Capussotti L. et al. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the RISTOS project. Ann. Surg. 2006; 243 (1): 89–95.
2. Ajori L., Nazari L., Mazloomfard M.M., Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch. Gynecol. Obstet. 2012; 285 (3): 677– 682. DOI: 10.1007/s00404-011-2023-6.
3. Bergqvist D., Agnelli G., Cohen A.T. et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N. Engl. J. Med. 2002; 346 (13): 975–980. DOI: 10.1056/NEJMoa012385.
4. Carli F., Charlebois P., Baldini G., Cachero O., Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can. J. Anaesth. 2009; 56 (11): 837–842. DOI: 10.1007/s12630-009-9159-x.
5. Carter J., Philp S. Assessing outcomes after fast track surgical management of corpus cancer. Open Journal of Obstetrics and Gynecology. 2011; 1 (3): 139– 143. DOI: 10.4236/ojog.2011.13026.
6. Carter J., Philp S. Development and Extended Experience with a Fast Track Surgery Program. Queenstown, New Zealand: Australian Society of Gynaecological Oncologists Annual Scientific Meeting Millbrook Resort; 2011.
7. Carter J., Philp S., Arora A. Fast track gynaecologic surgery in the overweight and obese patient. Int. J. Clinical Medicine. 2010; 1 (2): 64–69. DOI: 10.4236/ijcm.2010.12011.
8. Carter J., Philp S., Arora V. Discharge on postop day 2 after major gynaecological surgery. Is it possible? Oral Presentation 25th Annual Scientific Meeting Australian Society of Gynaecological Oncologists; March 2010; Bunker Bay, Western Australia.
9. Carter J., Philp S., Arora V. Early discharge after major gynaecological surgery: advantages of fast track surgery. Open Journal of Obstetrics and Gynecology. 2011; 1 (1): 1–5. DOI: 10.4236/ojog.2011.11001.
10. Carter J., Philp S., Arora V. Poster presentation. Extended experience with an enhanced surgical recovery program. Proceedings of the 13th Biennial Meeting of the International Gynecologic Cancer Society; 2010. Prague, Czech Republic, European Union.
11. Carter J., Szabo R., Sim W.W. et al. Fast track surgery: a clinical audit. Aust N. Z. J. Obstet. Gynaecol. 2010; 50 (2): 159–163. DOI: 10.1111/j.1479-828X.2009.01134.x.
12. Dierking G., Duedahl T.H., Rasmussen M.L. et al. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial. Acta Anaesthesiol. Scand. 2004; 48 (3): 322– 327. DOI: 10.1111/j.0001-5172.2004.0329.x.
13. Fassoulaki A., Stamatakis E., Petropoulos G., Siafaka I., Hassiakos D., Sarantopoulos C. Gabapentin attenuates late but not acute pain after abdominal hysterectomy. Eur. J. Anaesthesiol. 2006; 23 (2): 136–141. DOI: 10.1017/S0265021505002048.
14. Fearon K.C.H., Ljungqvist O., Von Meyenfeldt M. et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin. Nutr. 2005; 24 (3): 466–477. DOI: 10.1016/j.clnu.2005.02.002.
15. Gilron I., Orr E., Tu D. A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy. Pain. 2005;113: 191–200. DOI:10.1016/j.pain.2004.10.008.
16. Guenaga K.K., Matos D., Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Syst. Rev. 2009; 1: CD001544. DOI: 10.1002/14651858.CD001544.pub4.
17. Kehlet H. Principles of fast track surgery: multimodal perioperative therapy programme. Chirurg. 2009; 80 (8): 687–689. DOI: 10.1007/s00104-0091675-2.
18. Kehlet H., Wilmore D.W. Evidence-based surgical care and the evolution of fast-track surgery. Ann. Surg. 2008; 248 (2): 189–198. DOI: 10.1097/SLA.0b013e31817f2c1a.
19. Kehlet H., Wilmore D.W. Multimodal strategies to improve surgical income. Am. J. Surg. 2002; 183 (6): 630–641.
20. Lassen K., Soop M., Nygren J. et al. Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery after Surgery (ERAS) Group recommendations. Arch. Surg. 2009; 144 (10): 961–969. DOI: 10.1001/archsurg.2009.170.
21. Lv D., Wang X., Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database of Syst. Rev. 2010; 6: CD008239. DOI: 10.1002/14651858.CD008239.
22. Radhakrishnan M., Bithal P.K., Chaturvedi A. Effect of preemptive gabapentin on postoperative pain relief and morphine consumption following lumbar laminectomy and discectomy: a randomized, double-blinded, placebo-controlled study. J. Neurosurg. Anesthesiol. 2005; 17 (3): 125–128.
23. Ramirez J.M., Blasco J.A., Roig J. et al. Enhanced recovery in colorectal surgery: a multicenter study. BMC Surgery. 2011; 11: 9. DOI: 10.1186/1471-2482-11-9.
24. Rasmussen M.S., Jorgensen L.N., Wille-Jorgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database of Syst. Rev. 2009; 1: CD004318. DOI: 10.1002/14651858.CD004318.pub2.
25. Sen H., Sizlan A., Yanarates O. et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth. and Analg. 2009; 109 (5): 1645–1650. DOI: 10.1213/ANE.0b013e3181b65ea0.
26. Sweetland S., Green J., Liu B. et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ. 2009; 339: b4583. DOI: https://doi.org/10.1136/bmj.b4583.
27. Turan A., Karamanlioğlu B., Memiş D., Usar P., Pamukcu Z., Ture M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesth. and Analg. 2004; 98 (5): 1370–1373. DOI: 10.1213/01.ANE.0000108964.70485.B2.
28. Varadhan K., Neal K., Dejong C.H.C., Fearon K.C.H., Lobo D.N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomised controlled trials. Clin. Nutr. 2010; 29 (4): 434–440. DOI: 10.1016/j.clnu.2010.01.004.
29. Varadhan K.K., Lobo D.N., Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit. Care Clin. 2010; 26 (3): 527–547. DOI: 10.1016/j.ccc.2010.04.003.
30. К.В. Пучков, Н.М. Подзолкова, В.В. Коренная. «Fast Track»: Хирургические протоколы ускоренной реабилитации в оперативной гинекологии: учебное пособие. М.: РМАПО МЗ РФ; 2015.
Obstetrics and Gynaecology of Saint-Petersburg. 2017; : 70-75
Results of using the program of enhanced recovery after surgery in gynecological patients
Abstract
Objectives: to evaluate the effectiveness of using the program of enhanced recovery after surgery in patients with gynaecological profile.
Methods. Since 2012, in the Center for Clinical and Experimental Surgery were introduced protocols of enhanced recovery after operation for surgical, coloproctological and gynaecological patients. Since 2012 up to the 2015 were treated 975 patients with uterine myoma, 198 patients with endometriosis and 19 patients with endometrial cancer: of 1192 patients. For each of them was performed an individual plan, all elements of which were recorded in a special card. Protocol for gynecological patients was differed as it included a paragraph about hypoestrogenic violations after surgery.
Results. We comparing the early postoperative period after a fasttrack surgery and it was noted that using a traditional management of patients conduct problems with motor-evacuation function of the intestine in 5 times more often (8% versus 1.6% patients after surgery), postoperative vomiting in 6 times more often (12.2 % versus 2%) and the need for analgesic opioid was 34% higher. Readmissions took three patients. Reoperation does not require in any of the patients.
Conclusions. Using the protocol of enhanced recovery after operations in patients with gynaecological problems improves the early postoperative period, reduce postoperative pain, the risk of intestinal paresis and reduce the rehabilitation period.
References
1. Agnelli G., Bolis G., Capussotti L. et al. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the RISTOS project. Ann. Surg. 2006; 243 (1): 89–95.
2. Ajori L., Nazari L., Mazloomfard M.M., Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch. Gynecol. Obstet. 2012; 285 (3): 677– 682. DOI: 10.1007/s00404-011-2023-6.
3. Bergqvist D., Agnelli G., Cohen A.T. et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N. Engl. J. Med. 2002; 346 (13): 975–980. DOI: 10.1056/NEJMoa012385.
4. Carli F., Charlebois P., Baldini G., Cachero O., Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can. J. Anaesth. 2009; 56 (11): 837–842. DOI: 10.1007/s12630-009-9159-x.
5. Carter J., Philp S. Assessing outcomes after fast track surgical management of corpus cancer. Open Journal of Obstetrics and Gynecology. 2011; 1 (3): 139– 143. DOI: 10.4236/ojog.2011.13026.
6. Carter J., Philp S. Development and Extended Experience with a Fast Track Surgery Program. Queenstown, New Zealand: Australian Society of Gynaecological Oncologists Annual Scientific Meeting Millbrook Resort; 2011.
7. Carter J., Philp S., Arora A. Fast track gynaecologic surgery in the overweight and obese patient. Int. J. Clinical Medicine. 2010; 1 (2): 64–69. DOI: 10.4236/ijcm.2010.12011.
8. Carter J., Philp S., Arora V. Discharge on postop day 2 after major gynaecological surgery. Is it possible? Oral Presentation 25th Annual Scientific Meeting Australian Society of Gynaecological Oncologists; March 2010; Bunker Bay, Western Australia.
9. Carter J., Philp S., Arora V. Early discharge after major gynaecological surgery: advantages of fast track surgery. Open Journal of Obstetrics and Gynecology. 2011; 1 (1): 1–5. DOI: 10.4236/ojog.2011.11001.
10. Carter J., Philp S., Arora V. Poster presentation. Extended experience with an enhanced surgical recovery program. Proceedings of the 13th Biennial Meeting of the International Gynecologic Cancer Society; 2010. Prague, Czech Republic, European Union.
11. Carter J., Szabo R., Sim W.W. et al. Fast track surgery: a clinical audit. Aust N. Z. J. Obstet. Gynaecol. 2010; 50 (2): 159–163. DOI: 10.1111/j.1479-828X.2009.01134.x.
12. Dierking G., Duedahl T.H., Rasmussen M.L. et al. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial. Acta Anaesthesiol. Scand. 2004; 48 (3): 322– 327. DOI: 10.1111/j.0001-5172.2004.0329.x.
13. Fassoulaki A., Stamatakis E., Petropoulos G., Siafaka I., Hassiakos D., Sarantopoulos C. Gabapentin attenuates late but not acute pain after abdominal hysterectomy. Eur. J. Anaesthesiol. 2006; 23 (2): 136–141. DOI: 10.1017/S0265021505002048.
14. Fearon K.C.H., Ljungqvist O., Von Meyenfeldt M. et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin. Nutr. 2005; 24 (3): 466–477. DOI: 10.1016/j.clnu.2005.02.002.
15. Gilron I., Orr E., Tu D. A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy. Pain. 2005;113: 191–200. DOI:10.1016/j.pain.2004.10.008.
16. Guenaga K.K., Matos D., Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Syst. Rev. 2009; 1: CD001544. DOI: 10.1002/14651858.CD001544.pub4.
17. Kehlet H. Principles of fast track surgery: multimodal perioperative therapy programme. Chirurg. 2009; 80 (8): 687–689. DOI: 10.1007/s00104-0091675-2.
18. Kehlet H., Wilmore D.W. Evidence-based surgical care and the evolution of fast-track surgery. Ann. Surg. 2008; 248 (2): 189–198. DOI: 10.1097/SLA.0b013e31817f2c1a.
19. Kehlet H., Wilmore D.W. Multimodal strategies to improve surgical income. Am. J. Surg. 2002; 183 (6): 630–641.
20. Lassen K., Soop M., Nygren J. et al. Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery after Surgery (ERAS) Group recommendations. Arch. Surg. 2009; 144 (10): 961–969. DOI: 10.1001/archsurg.2009.170.
21. Lv D., Wang X., Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database of Syst. Rev. 2010; 6: CD008239. DOI: 10.1002/14651858.CD008239.
22. Radhakrishnan M., Bithal P.K., Chaturvedi A. Effect of preemptive gabapentin on postoperative pain relief and morphine consumption following lumbar laminectomy and discectomy: a randomized, double-blinded, placebo-controlled study. J. Neurosurg. Anesthesiol. 2005; 17 (3): 125–128.
23. Ramirez J.M., Blasco J.A., Roig J. et al. Enhanced recovery in colorectal surgery: a multicenter study. BMC Surgery. 2011; 11: 9. DOI: 10.1186/1471-2482-11-9.
24. Rasmussen M.S., Jorgensen L.N., Wille-Jorgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database of Syst. Rev. 2009; 1: CD004318. DOI: 10.1002/14651858.CD004318.pub2.
25. Sen H., Sizlan A., Yanarates O. et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth. and Analg. 2009; 109 (5): 1645–1650. DOI: 10.1213/ANE.0b013e3181b65ea0.
26. Sweetland S., Green J., Liu B. et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ. 2009; 339: b4583. DOI: https://doi.org/10.1136/bmj.b4583.
27. Turan A., Karamanlioğlu B., Memiş D., Usar P., Pamukcu Z., Ture M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesth. and Analg. 2004; 98 (5): 1370–1373. DOI: 10.1213/01.ANE.0000108964.70485.B2.
28. Varadhan K., Neal K., Dejong C.H.C., Fearon K.C.H., Lobo D.N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomised controlled trials. Clin. Nutr. 2010; 29 (4): 434–440. DOI: 10.1016/j.clnu.2010.01.004.
29. Varadhan K.K., Lobo D.N., Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit. Care Clin. 2010; 26 (3): 527–547. DOI: 10.1016/j.ccc.2010.04.003.
30. K.V. Puchkov, N.M. Podzolkova, V.V. Korennaya. «Fast Track»: Khirurgicheskie protokoly uskorennoi reabilitatsii v operativnoi ginekologii: uchebnoe posobie. M.: RMAPO MZ RF; 2015.
