Pankreas Cerrahisi Öncesinde Hastanın Preoperatif Değerlendirilmesi
Özet
Pankreas cerrahisi, cerrahi teknikler ve postoperatif bakımdaki gelişmelere rağmen yüksek morbidite ve mortalite oranlarıyla ilişkili majör bir girişim olmayı sürdürmektedir. Bu nedenle perioperatif yönetim sürecinde cerrah, anestezist ve yoğun bakım uzmanından oluşan multidisipliner bir takım yaklaşımı kritik bir rol oynamaktadır. Başarılı sonuçlar elde etmek adına, ameliyat gününden önce dikkatli bir hasta seçimi, bireyselleştirilmiş preoperatif değerlendirme ve kapsamlı klinik optimizasyon sağlanmalıdır. Preanestezik değerlendirme kapsamında hastanın medikal öyküsü ayrıntılı incelenmeli, fizik muayenesi yapılmalı, risk sınıflandırması (ASA skorlaması) belirlenmeli ve gerekli laboratuvar tetkikleri ile konsültasyonlar tamamlanmalıdır. Pankreas cerrahisi adaylarında malnütrisyon, tıkanma sarılığı, diyabet, anemi, sigara kullanımı gibi spesifik durumlar ile kardiyovasküler ve solunum sistemi komorbiditeleri perioperatif riskleri önemli ölçüde artırmaktadır. Ameliyat öncesi süreçte beslenme desteğinin verilmesi, solunum rehabilitasyonu, uygun antitrombotik ve antibiyotik profilaksisinin planlanması gibi optimizasyon stratejileri hayati önem taşır. Son yıllarda klinik uygulamaya giren Cerrahiden Sonra Gelişmiş İyileşme (ERAS) protokolleri, hastanın stres yanıtını azaltarak postoperatif iyileşme sürecini hızlandırmakta ve bakım kalitesini artırmaktadır. Sonuç olarak, detaylı bir preoperatif hazırlık ve hedefe yönelik intraoperatif-postoperatif planlama, komplikasyonları azaltarak hasta sağkalımı ve yaşam kalitesini doğrudan optimize etmektedir.
Pancreatic surgery remains a major procedure associated with high morbidity and mortality rates, despite advancements in surgical techniques and postoperative care. Therefore, a multidisciplinary team approach comprising surgeons, anesthesiologists, and intensive care specialists plays a critical role in perioperatif management. To achieve favorable outcomes, careful patient selection, individualized preoperative assessment, and comprehensive clinical optimization must be established before the day of surgery. The preanesthetic evaluation should include a detailed review of medical history, physical examination, risk stratification (ASA classification), and necessary laboratory tests and consultations. In candidates for pancreatic surgery, specific conditions such as malnutrition, obstructive jaundice, diabetes, anemia, smoking, and cardiovascular or respiratory comorbidities significantly increase perioperative risks. Optimization strategies, including preoperative nutritional support, respiratory rehabilitation, and appropriate antithrombotic and antibiotic prophylaxis, are of vital importance. Recently implemented Enhanced Recovery After Surgery (ERAS) protocols reduce the surgical stress response, thereby accelerating postoperative recovery and improving the quality of care. In conclusion, meticulous preoperative preparation combined with targeted intraoperative and postoperative planning directly minimizes complications, thereby optimizing patient survival and overall quality of life.
Referanslar
Rahib L., Smith B.D., Aizenberg R., et al. Projecting cancer incidence and deaths to 2030: The unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res. 2014; 74(11): 2913-2921. Doi:10.1158/0008-5472.can-14-0155
Malvezzi M., Bertuccio P., Levi F., et al. European cancer mortality predictions for the year 2014. Annals of Oncology 2014; 25 (8): 1650-1656. Doi:10.1093/annonc/mdu138
Malvezzi M., Bertuccio P., Rosso T., et al. European cancer mortality predictions for the year 2015:does lung cancer have the highest death rate in EU women? Annals of Oncology April 2015; 26(4): 779-786. Doi:10.1093/annonc/mdv001
Siegel R.L., Miller K.M., Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65: 5-29. Doi:10.3322/caac.21254
Ducreux M., Sa Cuhna A., Caramella C., et al. Cancer of the pancreas: ESMO Hollebecque A., Burtin P., Goere D., Seufferlein T., Clinical Practice Guidelines for diagnosis, treatment and follow up. Annals of Oncology 2015; 26 (supplement5): 56-68. Doi:10.1093/annonc/mdv295
Masiak-Segit W., Rawic-Pruszynski K.,Skorzewska M., et al. Surgical treatment of pancreatic cancer. Pol. Przegl. Chir. 2018: 90(2); 40-48. Doi: 10.5604/01.3001.0011.7453
Sun V., Ruel N., Chung V., et al. Pilot study of an interdisciplinary supportive care planning intervention in pancreatic cancer. Support Care Cancer 2016; 24 (8): 3417-3424. Doi:10.1007/s00520-016-3155-9
Marinelli V., Danzi O.P., Mazzi M. A., et al. PREPARE: PreoPerative Anxiety REduction. One-year feasibility RCT on a brief psychological intervention for pancreatic cancer patients prior to major surgery. Frontiers in Psychology 2020; 11, Article 362:1-14. Doi:10.3389/fpsyg.2020.00362
Türk Anesteziyoloji ve Reanimasyon Derneği (TARD) Anestezi Uygulama Kılavuzları- Preoperatif Değerlendirme 2015 (17/07/2021 tarihinde www.tard.org.tr/akademi/?p=kilavuz-detay&bID=2&session=13709117974720-27418235949440 adresinden ulaşılmıştır.)
Practice Advisory for Preanesthesia Evaluation- An Updated Report by the American Society of Anesthesiologists task force on Preanesthesia Evaluation. Anesthesiology March 2012; 116 (3): 522-538. Doi:10.1097/ALN.0b013e31823c1067
Barash, P.G., Cullen B.F., Stoelting R.K., Cahalan M.K., Stock M.C., Ortega R., Sharar S.R., Holt N.F. (2020). Klinik Anestezi. (Berrin Işık, Ömer Kurtipek, Çev. Ed.) Ankara: Güneş Tıp Kitabevleri
Marandola M., Albante A. Anaesthesia and pancreatic surgery: Techniques, clinical practice and pain management. World J Anesthesiol 2014; 3(1): 1-11. Doi:10.5313/wja.v3.i1.1
De Pietri L., Montalti R., and Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol 2014; 20 (9): 2304-2320. Doi: 10.3748/wjg.v20.i9.2304
Grade M., Quintel M., Ghadimi B.M. Standard perioperative management in gastrointestinal surgery. Langenbecks Arch Surg 2011; 396: 591-606. Doi:10.1007/s00423-011-0782-y
American Society of Anesthesiologists. (Last Amended: December 13, 2020; Original Approval: October 15, 2014). ASA Physical Status Classification System. (06/09/2021 tarihinde https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system adresinden ulaşılmıştır.)
Kullavanijaya P., Treeprasertsuk S., Thong-Nyam D., et al. Adenocarcinoma of the pancreas: the clinical experience of 45 histopathologically proven patients, a 6 year study. J Med Assoc Thai 2001 May; 84(5):640-647.
Riall T.S., Reddy D.M., Nealon W.H., et al. The effect of age on short-term outcomes after pancreatic resection: a population-based study. Annals of Surgery September 2008; 248(3):459-467. Doi: 10.1097/SLA.0b013e318185e1b3
Myatra S., Divatia J.V., Jibhkate B., et al. Preoperative assessment and optimization in periampullary and pancreatic cancer. Indian Journal of Cancer, January-March 2011;48(1):86-93. Doi: 10.4103/0019-509X.75839
Schlippert W., Lucke D., Anuras S., et al. Carcinoma of the papilla of vater- a review of fifty-seven cases. Am J Surg 1978;135: 763-770. Doi: 10.1016/0002-9610(78)90160-5
Ghaferi A.A., Birkmeyer J.D., Dimick J.B. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361(14):1368-1375. Doi: 10.1056/NEJMsa0903048
Lundstrom L.H., Vester-Andersen M., Moller A.M., et al. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177088 patients. British Journal of Anaesthesia 107(5): 659-667. Doi:10.1093/bja/aer292
Canet J., Gallart L., Gomar C., et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010;113: 1338-1350. Doi: 10.1097/ALN.06013e3181fc6e0a
Lawrence V.A., Dhanda R., Hilsenbeck S., et al. Risk of pulmonary complications after elective abdominal surgery. Chest 1996; 110 (3): 744-750. Doi:10.1378/chest.110.3.744
Hanna M., Feld M., Sampliner J.E. Preoperative cardiac assessment of the candidate for majör resective pancreatic surgery. Surgical Clinics of North America 2001; 81 (3): 575-578. Doi:10.1016/S0039-6109(5)70144-4
Lee T.H., Marcantonio E.R., Mangione C.M., et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of majör noncardiac surgery. Circulation 1999; 100: 1043-1049. Doi: 10.1161/01.CIR.100.10.1043
Mangano D.T., Layug E.L., Wallace A., et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. The New England Journal of Medicine 1996; 335(23): 1713-1721. Doi:10.1056/NEJM199612053352301
Alagiakrishnan K., Banach M., Jones L.G., et al. Update on diastolic heart failure or heart failure with presenved ejection fraction in the older adults. Annals of Medicine 2013; 45(1): 37-50. Doi:10.3109/07853890.2012.660493
Devereaux P.J., Yusuf S., Yang H., et al. Are the recommendations to use perioperative β-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? CMAJ 2004; 171(3): 245-247. Doi:10.1503/cmaj.1031619
Skrlin S., Hou V. A review of perioperative statin therapy for noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2010; 14(4): 283-290. Doi: 10.1177/1089253210386387
Khorana A.A, Fine R.L. Pancreatic cancer and thromboembolic disease. Lancet Oncology 2004; 5(11): 655-663. Doi:10.1016/S1470-2045(04)01606
Bratzler D.W., Houck P.M. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. The American Journal of Surgery 2005; 189: 395-404. Doi: 10.1016/j.amjsurg.2005.01.015
Turhan V.B.(2021). Periampuller bölge tümörlerinde preoperatif değerlendirme. Vahit Onur Gül, Mutlu Şahin, Münire Babayiğit, Veysel Barış Turhan (Ed.), Peroperatif Hasta Yönetimi içinde (s. 99-107). Ankara: Berikan Yayınevi
An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healty patients undergoing elective procedures. Anesthesiology 2017; 126(3): 376-393. Doi:10.1097/ALN.0000000000001452
Egbert L.D., Battit G.E., Turndorf H., et al. The value of the preoperative visit by an anesthetist. JAMA 1963; 185(7): 553-555. Doi: 10.1001/jama.1963.033060070021016
Hallet J., Davis L.E., Mahar A.L., et al. Patterns of symptoms burden in neuroendocrine tumors: a population-based analysis of prospective patient-reported outcomes. The Oncologist 2019; 24: 1384-1394. Doi: 10.1634/theoncologist.2019-0112
Jiang W.G., Puntis M.C. Immune dysfunction in patients with obstructive jaundice, mediators and implications for treatments. HPB Surg 1997; 10: 129-142.
Katz S. C., Ryan K., Ahmed N., et al. Obstructive jaundice expands intrahepatic regulatory T cells, which impair liver T lymphocyte function but modulate liver cholestasis and fibrosis. J Immunol 2011;187 (3): 1150-1156. Doi:10.4049/jimmunol.1004077
Van der Gaag N.A., Klock J.J., de Castro S.M.M., et al. Preoperative biliary drainage in patients with obstructive jaundice: History and current status. J Gastrointest Surg 2009; 13: 814-820. Doi: 10.1007/s11605-008-0618-4
American Society of Anesthesiologists (2020). ASA and APSF joint statement on elective surgery and anesthesia for patients after COVID-19 infection. (26/08/2021 tarihinde https://www.asahq.org/about-asa/newsroom/news-releases/2020/12/asa-and-apsf-joint-statement-on-elective-surgery-and-anesthesia-for-patients-after-covid-19-infection adresinden ulaşılmıştır.)
COVIDSurg Collaborative, GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia 2021; 76: 748-758. Doi: 10.1111/anae.15458
World Federation of Societies of anaesthesiologists. (13/11/2018). Pai S., Hughes T. Perioperative management and anaesthetic considerations for pancreatic resection surgery. (15/07/2021 tarihinde https://resources.wfsahq.org/atotw/perioperative-management-and-anaesthetic-considerations-for-pancreatic-resection-surgery/ adresinden ulaşılmıştır.)
Melloul E., Lassen K., Roulin D., et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg 2020; 44: 2056-2084. Doi: 10.1007/s00268-020-05462-w
