Utjecaj prijeoperacijske i rane poslijeoperacijske enteralne prehrane na stresni odgovor nakon laparoskopskih i otvorenih operacija : doktorski rad

UVOD Preoperativno gladovanje je standardni protokol u elektivnih kirurških bolesnika. Danas neka anesteziološka društva su ostavila mogućnost prihvaćanja liberalnijih preoperativnih protokola. Jedan od čimbenika koji uzrokuju usporeno pražnjenje želuca je opreracija i perioperativni stres odnosno perioperativna trauma. Veličinu stresa određuju bolesnikov komorbiditet ali i iskustvo svih sudionika u liječenju. U svim segmentima liječenja razvijaju se metode koje imaju za cilj smanjenja perioperativnog stresa. Metode regionalne anestezije i farmakoterapija, minuciozna kirurška tehnika te minimalno invazivni kirurški pristup samo su neki od njih. Bolesnici u kojih je perioperativna trauma (stres) veća imaju veću učestalost komplikacija te imaju subjektivno lošiji odgovor na liječenje. Kratkotrajni period preoperativnog gladovanja dovoljan je da promjeni metaboličko stanje bolesnika a time i odgovor na stres. Rana enteralna prehrana smanjuje učestalost komplikacija i poboljšava ishod liječenja. Netolerancija enteralne prehrane ovisi o brzini pražnjenja želuca. Brzina pražnjenja želuca određuje se paracetamolskim testom. CILJ RADA Procijeniti utječe li preoperativna enteralna prehrana bogata ugljikohidratima na stresni odgovor organizma procjenjeno kroz ispitivane parametre te na koji način ima utjecaja na postoperativno pražnjenje želuca. BOLESNICI I METODE RADA Rad je prospektivna randomizirana studija u koju je 116 bolesnika koji su operativno liječenih zbog kolelitijaze te zbog maligne bolesti debelog crijeva. Podjeljeni su u skupinu 1 (bolesnici koji su dobili preoperativnu enteralnu prehranu) i skupinu 2 (standardni protokol „ništa na usta“ 12 do 16 sati prije operacije). Stresni odgovor procjenjivan je kroz koncentraciju interleukina 6, 10 i čimbenika tumorske nekroze, C-reaktivnog proteina i kortizola u krvi. Paracetamolski test korišten je za procjenu brzine pražnjenja želuca. GLAVNI REZULTATI U bolesnika nakon laparoskopske kolecistektomije porast CRP-a je značajno manji u preoperativno hranjenih bolesnika. U preoperativno hranjenih bolesnika nakon laparoskopske kolecistektomije poslijepodnevnne postoperativne vrijednosti pokazuju normalan, fiziološki pad vrijednosti kortizola, dok u bolesnika koji nisu hranjeni postoperativne vrijednosti kortizola rastu i iznad jutranjih vrijednosti. U hranjenih bolesnika interleukin 6 je značajno manje raste nego u bolesnika koji nisu bili preoperativno hranjeni (60,9 prema 144,1 pg/ml; p<0,01). Koncentracija paracetamola raste brže i postiže više vrijednosti 60 minuta nakon davanja u skupini bolesnika koji su primali preoperativnu prehranu. U nehranjenih bolesnika najveće vrijednosti postižu se tek 120 minuta nakon davanja. ZAKLJUČCI Na osnovu iznesenih rezultata može se reći kako preoperativna peroralna prehrana bogata ugljikohidratima ima utjecaj na stresni odgovor organizma. Preoperativnim davanjem enteralne prehrane u svih bolesnika ubrzava se oporavak normalizacije brzine pražnjenja želuca, odnosno motiliteta gastroduodenalnog segmenta.INTRODUCTION The strict ‘nil-by-mouth’ from midnight rule, before elective surgery was introduced to ensure an empty stomach at the time of anaesthesia. Over the last decade several shown that more liberal rules may be of considerable benefit to the patient. Delayed gastric emptying is caused by operative trauma and perioperative stress response. Level of that stress response is determined by preoperative morbidity and also experience of all medical staff included in treatment. Within all fields of treatment several new methods are developed in order to reduce surgical stress. It has been shown that patients with more severe perioperative stress have more incidences of postoperative complications. Undernourished patients have more postoperative, mainly septic complications, higher mortality and increased costs of treatment. Even a short fasting period change patient’s response to stress. Early postoperative feeding stimulates gastrointestinal motility, prevents mucosal damage and translocations of microorganisms and with that reduces morbidity. Oral feeding intolerance is the most frequent cause for discontinuing oral feeding. Paracetamol absorption test is one of the most valuable tests for gastric emptying evaluation and continuing oral feeding. AIM The aim of the present study was to investigate the possible effects of preoperative carbohydrate fluid administration on postoperative perioperative stress response and postoperative gastric emptying. METHODS Study is prospective, randomized, double blinded study. A total of 116 patients with cholelithiasis and colorectal carcinoma were included. They were randomized in the group 1 (with preoperative enteral feeding) and group 2 (with standard protocol “nothing by mouth” 12 to 16 hours prior to surgery). Stress response has been evaluated through changes in concentration of interleukins 6, 10 and tumor necrosis factor and non-specific parameters as C-reactive proteins and cortisol. For the evaluation of the gastric emptying and gastroduodenal motility paracetamol absorption test has been used. RESULTS After laparoscopic cholecystectomy in patients who did not received preoperative feeding rise in CRP concentration is significantly higher. Afternoon cortisol levels in both groups rise above morning levels. Cortisol levels after laparoscopic cholecystectomy in patients with preoperative feeding afternoon shows normal physiological decline whereas in fasted group cortisol concentration rise over morning levels. In patients with oral feeding IL-6 postoperative levels are significantly lower than in fasted group. (60,9 vs 144,1 pg/ml; p