ERAS and Immunity

Giulio Mari Dario Maggioni

Chirurgia Generale, ASST Monza, Presidio di Desio

Bergamo, 22-23 Maggio 2017

Enhanced Recovery in Gynecologic Surgery and

Oncology, Italian and American innovations

From Fast Track to ERAS

Understanding into post-operative programs. Analysis of Surgical Stress Response Improvement of post operative outcomes

A matter of words

2007-2012

2012-2017

2007-2017

Surgical Stress Response Biochemical parameters

WBC PCR PCT IL - 1 IL – 6 GF C – peptide Cortisol

Some of them are normally used in clinical practice

Albumine Pre - albumine Triglicerid Colesterol

Surgical Stress Response - IL-6

IL-6 is a multifunctional cytokine with a central role in many physiological inflammatory and immunological processes. Due to its major role in initiation as well as resolving inflammation, deregulation of IL-6 is a mainstay of acute and chronic inflammation.

Gene of the month: Interleukin 6 (IL-6) J Ataie-Kachoie

Clin Pathol 2014;67:11 932-937 16 July 2014

Laparoscopic surgery as independent factor in surgical stress response

It is of interest therefore that it has recently been reported that of the recommended ERAS components, only laparoscopic surgery, early oral intake, and early mobilization were identified as independent determinants of early recovery

Only laparoscopic series should be taken into consideration within RCT or not

Surgical Stress Response - Analgesia

There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.

Surgical Stress Response Insuline Sensivity

The implementation of a targeted ERAS program has been shown to modulate perioperative insulin sensitivity, thus improving postoperative outcomes and accelerating the return of baseline function.

Surgical Stress Response Immunonutrition

A decrease in the total number of complications was observed in the immunonutrition group compared with the control group, primarily due to a significant decrease in infectious complications (23.8% vs. 10.7%, P ¼ 0.0007)

LAFA Trial

In the LAFA trial, it was also shown that the accelerated recovery is correlated more to type of surgery and less to aftercare. These results are comparable in this study

In conclusion, laparoscopic technique and an FT rehabilitation program effectively inhibited post-operative release of inflammatory factors and offered good protection for postoperative cell immunity with a reduction in peri-operative trauma and stress.

Our experience – Fast Track

First bowel movement day 0.3 ± 0.647 in FT versus 1.73± 0.483 SC (P< 0.005).

First flatus day 0.9 ± 0.78 in FT versus 2.1± 0.94 SC (P < 0.005).

Passage of stool happened at day 1.6 ± 0.966 in FT versus 5 ± 1.79 in SC (P < 0.005).

Solid diet tolerated at day 1.2± 0.421 in FT versus 3.81 ± 0.982 in SC (P < 0.005).

60 meters walk in day 1.3± 0.82 versus 3.55 ± 0.483 in SC (P < 0.005).

Day of discharge was 4.7± 2.4 in FT versus day 7.65 ± 2.4 SC (P < 0.005).

Our experience - Analgesia

Analgesia in group 1 was made with spinal injection 30 min before surgery of morphine 0.2–0.3 mg according to patient’s weight, morphine patient controlled analgesia (PCA).

In group 2 analgesia was made with paracetamol 1 g every 6 h, ketorolac every 12 h, and lidocaine wound infiltration

Our experience - ERAS

Results

ERAS protocol applied to colorectal laparoscopic surgery significantly reduces IL-6 and CRP levels postoperatively compared to standard care. Attenuated stress response leads to early liver protein synthesis resumption in patients undergoing an enhanced program.

First flatus happened at day 1.6±0.7 in EG versus 2.1±0.8 SG (P<0.05). There was no difference between groups for passage of stool. Solid meal was tolerated at day 1.5±0.9 in EG versus 3±0.5 in SG (P<0.05). EG patients could walk at least 100m on day 1.5±0.7 versus 2.6±0.9 in SG (P<0.05). Day of discharge was 5±2.6 in EG versus 7.2±3 SG (P<0.05)

Outcomes

Conclusions

ERAS in laparoscopic colorectal surgery: affects SSR improves outcomes lowers complication