[Anaesthesia and intensive care during intraoperative intraperitoneal hyperthermic chemotherapy in patients with gastric cancer (literature review and own clinical experience)].

UNLABELLED: Despite a steady decline in the incidence in recent decades, gastric cancer remains one of the most frequent causes of death from cancer in the world. By the time of diagnosis the tumor process is locally advanced or generalized in nearly 70% of patients that reduces the possibility of radical surgical treatment. Peritoneal carcinomatosis is a one of the main causes of treatment failure. There patients need complex treatment with cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy (IHIC) to improve the quality and duration of life. Today in Russia, surgeries with IHIC are performed in a very limited number of oncology hospitals, thus there is no unified approach to the perioperative management of these patients. DESIGN: Since November 2010 in our institution we started a prospective clinical study of the use of intraoperative hyperthermic intraperitoneal chemotherapy in patients with locally advanced or metastatic gastric cancer. MATERIALS AND METHODS: The study included 30 patients (18 men and 12 women) who underwent transabdominal gastrectomy with extended lymphadenectomy D2, supplemented principled cholecystectomy and oophorectomy (in women). Mean age was 48.5 ± 5.3 years. Technique involved the use of regional anesthesia com- ponent and inhalation anesthetic sevoflurane. Preoperative preparation included enteral nutrition (based on 25-30 kcal/ kg/day), liver protection (intravenous remaxol infusion of 500 ml/day for 3 days prior to surgery), antisecretory and antifermental therapy (omeprazole 40 mg/day, 100 mg octreotide for 2 h before surgey, aprotinin sulfate 30000 after induction of anesthesia), antioxidant and immunomodulatory therapy (galavit, cytoflavin, ceruloplasmin vitamin C), anticoagulant prophylaxis (enoxaparin sodium 40 mg on the evening before surgery). RESULTS: Analysis of the world and our own clinical experience with intraoperative hyperthermic intraperitoneal chemotherapy in a comprehensive plan of treatment of patients with gastric cancer showed that the this aggressive, but highly effective technique can be requires not only careful patient selection according to the criteria, but also the use of special methods to protective therapy at all stages of the surgical treatment. Application of pathogenetic ways of protection from thermal injury, timely control and correction of homeostasis caused by the toxic effects of chemotherapy and burn peritoneum, early enteral nutrition and the use of organ-therapy reduce the risk of complications and achieve better results of treatment in cancer patients.

[The problem of perioperative care of patients with high risk of heart arrhythmias in oncosurgery].

This review is devoted to analysis of the world experience of perioperative care in patients with high risk of development and aggravation of heart rhythm and conduction disturbances. There was given the definition of the arrhythmia, their modern classification, described the mechanisms of formation and causes of long duration. Special attention is paid to the problem of perioperative arrhythmias in oncosurgery, which is characterized by the extent and traumatic interventions in reflexogenic zones in patients with nutritive deficiency, hypovolaemia, anemia, electrolyte imbalance. The problem of interaction of antiarrhythmic drugs with anaesthetics, possible complications and ways of correction of hemodynamically significant bradycardia with the help of drugs (atropine, sympathomimetics) and drug-free (transesophageal (TEECS) and invasive cardiac stimulation) methods. Describes approaches to the diagnosis and prediction of the risk of the arrhythmia development with the help of the analysis of Holter ECG results with e of heart rhythm variability (HRV) assessment.

[The algorith of preoperative cardiovascular therapy in high risk elderly oncology patients].

The study was based on 478 oncology patients (72.1 +/- 3.6 years old) with cardiovascular comorbidities operated from 1991 to 2008 in regards of abdominal and pelvic mainly 3rd stage tumors with multimodal general anesthesia (4.2 +/- 1.6 hours). In prospective group (n = 302) all patients received cardiovascular treatment, while in retrospective group (n = 176) only 48.9% received it. The evaluation of the cardiovascular therapy effect was based on the peri-operative and postoperative HR and BP dynamics. The occurrance of noticeable bradycardia and drop of BP lower than 90/60 mm Hg was considered as a deviation. It is revealed that the cardiovascular therapy with beta adrenoblockers and calcium antagonists leads to an intraoperative bradycardia in 59.8% and 73.7% of cases, while in patients without the aforementioned therapy in 26.6% and 46.4% of cases respectively (p < 0.05). Antiarrhythmics don't have a noticeable impact on the development of bradycardia (p = 0.204). Intraoperative hypotension on the basis of ATP inhibitor treatment developed in 92.2% of patients statistically significant (p < 0.01). Monotherapy with calcium antagonists or nitrates leads to the development of hypotension in 55.2% and 41.4% of cases respectively, though in patients without the given therapy a lot more often (p < 0.05). In the case of combined calcium antagonist/nitrate therapy hypotension develops in 55.5% of cases, and in 72.3% without the therapy (p < 0.05). For the means of prevention of cardiovascular complications during the surgical treatment it is appropriate to keep the therapy with nitrates, though vasodilatives should be canceled 12 hours before the surgery.

[Diagnosis and risk assessment of perioperative cardiovascular complications in geriatric patients in oncological surgery].

Cardiovascular events (CVE) developing at the stages of surgical treatment in 449 geriatric (aged 72 +/- 5.8 years) cancer patients with concomitant cardiovascular diseases (CVD) were quantitatively and qualitatively analyzed. Statistical analysis was used to compare and establish a discrepancy between the results of a predictable risk by the standard scale of the international perioperative CV risk index (ICVRI) and the actually developed complications. The logistic regression method was employed to analyze the risk factors included into the ICVRI scale. The risk factors that were best in predicting the development of CVE were determined. A mathematical formula was derived to estimate the adjusted prognosis of an individual cardiovascular risk. Based on their perioperative CV risk classification, the authors constructed an algorithm of a diagnostic search and surgical preparation tactics in seriously ill cancer patients with concomitant CVD. The algorithm has been put into the routine practice of the P. A. Herzen Moscow Research Institute of Oncology, which makes it possible to improve the results of surgical treatment in geriatric patients and to expand its indications. Examples of clinically applying the algorithm are given.

[Choice of components and a method of anesthesia in geriatric cancer patients with high cardiovascular risk].

Investigations were made at surgical treatment stages in 102 cancer patients (mean age 72 +/- 5.8 years) at high cardiovascular risk, who received continuous therapy that reduced heart rate and blood pressure, in order to compensate for the course of coronary heart disease and arterial hypertension. The time course of changes in the major circulatory and metabolic parameters was analyzed in patients during operations on the abdomen and small pelvis while using three different multimodal anesthetic techniques (general intravenous anesthesia-based diazepam, propofol, fentanyl, ketamine; sevofluorane-based inhalational; combined epidural and intravenous one). The advantages and limitations of the above methods were shown in patients on cardio- and vasotropic therapies. Correcting modes (transesophageal atrial pacing, morning-dose drug withdrawal) for its possible related bradycardiac and hypotensive disorders, which reduce a risk of perioperative cardiovascular complications, are set forth.