The morbidity and mortality after esophagectomy remains high despite significant improvements in the surgical procedures and perioperative care over the last several decades. In the field of esophageal cancer surgery, enhanced recovery programs based on the enhanced recovery after surgery (ERAS®) or Japanese ESsential Strategy for Early Normalization after Surgery with patient's Excellent satisfaction (ESSENSE) programs have recently been introduced and appear promising for achieving better outcomes. However, to date, such programs for early recovery after esophagectomy have lacked largescale, prospective, multicenter evidence. At present, integrated perioperative care aiming at the prophylaxis and control of postoperative infectious complications (represented by anastomotic leakage as a surgical site infection and pneumonia as a remote infection) may be a top-priority component for not only early recovery from esophagectomy but also improvement of the long-term survival and postoperative quality of life. Among the available modalities, seamless enteral nutrition throughout the perioperative period is expected to play a central role. In clinical practice, carrying out “standardized” nutritional care according to the clinical pathway prescribed beforehand in the days after operation can be difficult to apply in some cases, due to its surgical complexity and high morbidity rate, which limits the application of some enhanced recovery programs. Thus, we often need “individualized” perioperative management with adequate nutritional support, particularly in resumption of oral intake after esophagectomy. In addition, perioperative cancer rehabilitation and mental/social support should be kindly provided, particularly in elderly patients. Early recovery after esophageal cancer surgery may require the application of the latest knowledge and the perioperative practice of multi-occupational team medical care, according to the condition of each patient and facility.
Aim : Acute isovolemic anemia is commonly observed after surgery and negatively influences shortand long-term outcomes. Current blood management practices fail to deliver effective reversal of anemia. The aim of this study was to evaluate the efficacy and safety of ferric carboxymaltose to treat anemia following gastrectomy. Method : The FAIRY study was a patient-blind, randomized, phase 3, placebo-controlled, 12- week study was conducted between 4 February 2013 and 15 December 2015 to evaluate the ability of ferric carboxymaltose to correct acute isovolemic anemia. This study was conducted in seven centers across the Republic of Korea. The primary endpoint was the number of hemoglobin responders, defined as hemoglobin increase of ≥2 g/dL from baseline and/or ≥11 g/dL at week 12. Secondary endpoints included changes in hemoglobin and other iron parameters over time, percentage of patients requiring alternative anemia management, and quality of life at weeks 3 and 12. Results : 454 patients were randomized to receive ferric carboxymaltose (228 patients) or placebo (226 patients). The number of hemoglobin responders was significantly greater for ferric carboxymaltose versus placebo (200 patients [92.2%] vs 115 patients [54.0%] ; 90 P=0.001). Correction of anemia and improvements in iron parameters were significantly in favor of ferric carboxymaltose at all time points, and these patients required less alternative anemia management compared to placebo patients (1.8% vs 7.1% ; P=0.006). Improvements were observed for fatigue and dyspnea in the ferric carboxymaltose group. No grade 3 or 4 adverse events were recorded, and ferric carboxymlatose-related adverse events reported in more than one patient included injection site reaction and urticaria (both : 5 patients [2.3%]) Conclusions : Ferric carboxymlatose for postoperative blood management was safe and effective in correcting anemia and iron deficiency. In order to improve the recovery period, patients with low hemoglobin levels post-gastrectomy should receive intravenous ferric carboxymaltose.
Malnutrition leads to adverse effects on the short term and long term prognosis in patients with hepatobiliary malignant diseases who underwent radical surgery. The early detection of nutritional risk allows early intervention to prevent later complication. But there is no single gold standard objective measurement for the evaluation of nutritional status in the early period after radical surgery. Anthropometric measurement including body weight is commonly used in clinical practice because it is simple to use. Unfortunately, anthropometric measurement shows poor sensitivity in the diagnosis of malnutrition during the early perioperative period. In response to surgery, the released cytokines increase capillary membrane permeability, which leads to the redistribution of plasma proteins and fluid from vascular channels to interstitial spaces. The likely consequences of volume overload (i.e., pleural effusion, pulmonary edema, ascites, and generalized edema) lead to the increase in body weight. We have shown that the exploration of fluid dynamics using bioimpedance analysis is important in the balanced fluid management during perioperative period. At the same, increased extracellular water/total body water in fluid-imbalanced patients may indicate the development of ascites or fluid collections during postoperative period. Nutritional risk indicator based on albumin and body weight has been developed for the evaluation of the nutritional status and the efficacy of nutritional therapy. Nutritional risk indicator has limitations in the patients with hepatobiliary pancreatic malignant diseases because these patients show deficits in the protein synthesis including albumin due to liver dysfunction and pro-inflammatory proteins. Previously, we retrospectively reviewed medical records of sixty-five patients who underwent hepatectomy for hepatocellular carcinoma. Body weight, Body Mass Index (BMI) and laboratory parameters were compared at preoperative day and postoperative day 7. After the surgery, the level of lymphocyte, total protein, albumin, BUN, cholesterol, transthyretin significantly decreased, while the level of WBC and CRP significantly increased. The precise relationship between nutritional screening protein and the status of inflammation is still not clear ; however the degree of inflammation may have a significant influence in nutrition evaluation scale. Therefore, we analyzed the patients with hepatobiliary malignant disease who underwent radical surgery from Jan. 1, 2012 through Dec. 31, 2016. In order to accurately evaluate the nutrition scale after the hepato-biliary radical surgery, we suggest a new method of nutritional evaluation that can adjust the degree of inflammation during early postoperative period.
Introduction : This study aimed to evaluate of the efficacy of postoperative oral nutrition supplement after major gastrointestinal surgery. Methods : A prospective randomized controlled trial was conducted for 174 subjects who were discharged within 2 weeks after major gastrointestinal surgery. Subjects in study group were prescribed to take 400 ml/day of Encover® from the day of discharge for 8 weeks. The primary endpoint was the weight loss rate at 8 weeks after discharge compared with the pre-operative weight, and the secondary endpoints included the changes in body weight, body mass index, Patient-Generated Subjective Global Assessment, hematology/biochemistry tests, and adverse events evaluated at 2, 4, and 8 weeks after discharge. Results : The weight loss rate at 8 weeks after discharge was not different between two groups. (4.23±5.49% vs. 4.80±4.84%, p=0.4810). The level of lymphocyte count, cholesterol, protein, and albumin were significantly higher in study group after discharge. The incidence of adverse events with a severity score ≥ 3 was not different between two groups. (2.3% vs. 1.2%) Conclusions : Usefulness of routine oral nutritional support after major gastrointestinal surgery was not proven in terms of weight loss at 8 weeks after discharge. However, it can be beneficial for early recovery of biochemical parameters.
ERASガイドラインに「Intraoperative fluids should be balanced to avoid both hypo- and hypervolemia. Intraoperative goal directed fluid therapy should be considered on an individual basis」というのがある。術中輸液管理はハイポボレミアやハイパーボレミアを避けてバランスをとることが望ましい、そのために個人に見合った目標指向型輸液管理を考慮せよということである。手術による出血はハイポボレミアを招く最大の要因である。麻酔による血管拡張は静脈還流を低下させる。外科的出血を絶対的なハイポボレミア、麻酔によるものを相対的なハイポボレミアと呼ぶが、双方とも静脈還流の低下から心拍出量の低下を招く。それに対する処置を細胞外液で行うと大量に輸液が必要であるだけでなく、間質浮腫を起こし、術後合併症の原因となりやすい。一方、膠質液は血管内に止まるため、少量で効果的にハイポボレミアを補充できる。同時に開きすぎた静脈系のリザーバーを収縮させる血管収縮薬の併用も効果的である。 アルブミン製剤は膠質浸透圧を維持するのに、特に食道癌や肝臓癌などの大手術時に使われてきた。また、大量出血時の血管内volume expander としても使われてきた。アルブミン製剤は術後の低アルブミン血症の対症療法としても使われているが有効性のエビデンスは乏しい。第3 世代HES ボルベンはアルブミンの代替膠質液として十分なエビデンスもあり、また、アルブミンを凌ぐ性質も持っている。HES は血管内容量を保つため、希釈による術後のアルブミン値の低下は著明であるが、膠質浸透圧の低下は少ない。第3 世代HES ボルベンは第2 世代HES サリンヘス・ヘスパンダーと比べて止血凝固系への影響も少なく、使用可能量も50mL/kg/ 日と大幅に増えた。そのため、手術中のみならず、術後のハイポボレミアにも有効である。近年HES の腎障害に対して、欧州を中心に世界的な逆風が吹いた。そのエビデンスとなるRCT を詳細に検討すると第3 世代HES ボルベンに関して、死亡率、腎機能に否定的なものは一つもない。第3 世代HES は術中、術後の膠質液として、今後の周術期医療を大きく変えるポテンシャルを持った輸液である。