Междисциплинарный подход в хирургии к ведению пациентов высокого риска, основанный на принципах ERAS (Enhanced Recovery After Surgery – улучшенная реабилитация после хирургии) и fast track, включает в себя три блока: пред-, интра- и послеоперационный. Стратегия командной работы и коллективной ответственности за результат позволяет максимально эффективно и качественно оказывать хирургическую помощь пациентам с тяжелыми сопутствующими заболеваниями, пациентам старшей возрастной категории, а также перенесшим химио- и лучевую терапию. Включение в программу происходит уже на стадии абмулаторного осмотра и продолжается до выписки. Все компоненты программы основаны на принципах доказательной медицины и позволяют минимизировать риск предстоящего хирургического вмешательства, улучшить качество оказываемой помощи, сократить сроки пребывания пациента в стационаре.
Interdisciplinary approach in surgery for the management of patients at high risk, based on the principles of ERAS (Enhanced Recovery After Surgery) and fast track, includes three parts: pre-, intra- and post-operative. The strategy of teamwork and collective responsibility for the outcome maximizes and efficiently to provide surgical care to patients with severe comorbidities, patients over age category, and had undergone chemotherapy and radiation therapy. Inclusion in the program takes place at the stage of examination as an outpatient and continues to discharge. All components of the program are based on the principles of evidence-based medicine and to minimize the risk of the upcoming surgery, improve the quality of care, reduce the time the patient's stay in hospital.
Key words: thoracic surgery, abdominal surgery, anesthetic, early rehabilitation, fast track, ERAS, perioperative management, multidisciplinary approach
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2. Pearse RM, Harrison DA, James P et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006; 10: R81. DOI: 10.1186/cc4928
3. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991; 78: 355–60. DOI: http://dx.doi.org/10.1002/bjs.1800780327
4. Lee TH, Marcantonio ER, Mangione CM et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043–9. DOI: http://dx.doi.org/10.1161/01.cir.100.10.1043
5. Kheterpal S, Tremper KK, Heung M et al. Development and validation of an acute kidneyinjury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 2009; 110: 505–15. DOI: http://dx.doi. org/10.1097/aln. 0b013e3181979440
6. Fleisher LA, Beckman JA, Brown KA et al. AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2007; 116: e418–99. DOI: http://dx.doi.org/10.3410/ f.1098966.555143
7. Moriello C, Mayo NE, Feldman L, Carli F. Validating the six-minute walk test as a measure of recovery after elective colon resection surgery. Arch Phys Med Rehabil 2008; 89: 1083–9. DOI:http://dx.doi.org/10.1016/j.apmr.2007.11.031
8. Older P, Smith R, Hall A, French C. Preoperative cardiopulmonary risk assessment by cardiopulmonary exercise testing. Crit Care Resusc 2000; 2: 198–208. DOI: http://dx.doi.org/10.1017/cbo9780511544521.002
9. Houts PS, Doak CC et al. The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence. Patient Education Counseling 2006; 61 (Issue 2): 173–90. DOI: http://dx.doi.org/10.1016/j.pec. 2005.05.004
10. Mendelson CL. The aspiration of stomach contents into the lungs during obstetrics anesthesia. Am J Obstet Gynecol 1946; 52: 191–205. DOI: http://dx.doi.org/ 10.1097/00006254-194612000-00024
11. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; 4: CD004423. DOI: http://dx.doi.org/10.1002/14651858.cd004423
12. Smith I, Kranke P, Murat I et al. European Society of Anaesthesiology. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28: 556–69. DOI: http://dx.doi.org/10.1097/eja. 0b013e3283495ba1
13. Awad S, Varadhan KK, Ljungqvist O et al. A metha-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr 2013; 32: 34–44. DOI: http://dx.doi.org/10.1016/j.clnu.2012.10.011
14. Smith MD, McCall L, Plank L. Preoperative carbohydrate treatment for enchansing recovery after elective surgery. Cochrane Database Syst Rev 2014; 8: CD009161. DOI: http://dx.doi.org/10.1002/14651858.cd009161.pub2
15. Bluman LG, Mosca L, Newman N et al. Preoperative smoking habits and postoperative pulmonary complications. Chest 1998; 113: 883–9. DOI: http://dx.doi.org/ 10.1378/chest.113.4.883
16. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003; 238: 1–5. DOI: http://dx.doi.org/10.1097/01.sla.0000074980.39700.31
17. Lindstrom D, Sadr AO, Wladis A et al. Effects of a perioperative smoking сessation intervention on postoperative complications: a randomized trial. Ann Surg 2008; 248: 739–45. DOI: http://dx.doi.org/10.1097/sla.0b013e3181889d0d
18. Holte K, Nielsen KG, Madsen JL et al. Physiologic effects of bowel reparation. Dis Colon Rectum 2004; 47: 1397–402. DOI: http://dx.doi.org/10.1007/s10350-004-0592-1
19. Guenaga KF, Matos D, Castro AA et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005; 1: CD001544. DOI: http://dx.doi.org/10.1002/14651858.cd001544
20. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and metaanalysis. Int J Colorectal Dis 2011; 27: 803–10. DOI: http://dx.doi.org/10.1007/s00384-011-1361-y
21. Spyropoulos AC, Brotman DJ, Amin AN et al. Prevention of venous thromboembolism in the cancer surgery patient. leveClin J Med 2008; 75 (Suppl. 3): S17–S26. DOI: http://dx.doi.org/10.3949/ccjm.75.suppl_3.s17
22. National Institute for Health and Clinical Excellence. Venous Thromboembolism: Reducing the Risk. London: NICE. Clin Guidance 2010; 92. DOI: http://dx.doi.org/ 10.1136/bmj.c95
23. Kakkos SK, Caprini JA, Geroulakos G et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev 2008; 4: CD005258. DOI: http://dx.doi.org/10.1002/14651858.cd005258
24. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2009; 1: CD004318. DOI: http://dx.doi.org/10.1002/ 14651858. cd004318.pub2
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26. Chang SH, Krupnick AS. Perioperative antibiotics in thoracic surgery. Thoracic Surg Clin 2012; 22: 35–45. DOI: http://dx.doi.org/10.1016/j.thorsurg.2011.08.012
27. Lassen K, Coolsen M, Slim K et al. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2013; 37: 240–58. DOI: http://dx.doi.org/10.1007/s00268-012-1771-1
28. Caumo W, Hidalgo MP, Schmidt AP et al. Effect of preoperative anxiolysis on postoperative pain response in patients undergoing total abdominal hysterectomy. Anaesthesia 2002; 57: 740–6. DOI: http://dx.doi.org/10.1046/j.1365-2044.2002.02690.x
29. Moiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia. Anesthesiology 2002; 96: 725–41. DOI: http://dx.doi.org/10.1097/00000542-200203000-00032
30. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology 2010; 112: 220–5. DOI: http://dx.doi.org/10.1097/ aln.0b013e3181c6316e
31. Popping DM, Elia N, Van Aken HK et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259: 1056–67. DOI: http://dx.doi.org/10.1097/ sla.0000000000000237
32. Feldheiser A, Aziz O, Baldini G et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60 (3): 289–334. DOI: http://dx.doi.org/10.1111/aas.12651
33. Yates DR, Davies SJ, Milner HE, Wilson RJ. Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery. Br J Anaesth 2014; 112: 281–9. DOI: http://dx.doi.org/10.1093/bja/aet307
34. Murphy GS, Szokol JW, Marymont JH et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology 2008; 109: 389–98. DOI: http://dx.doi.org/10.1097/aln.0b013e318182af3b
35. Geldner G, Niskanen M, Laurila P et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67: 991–8. DOI: http://dx.doi.org/10.1111/j.1365-2044.2012.07197.x
36. Blobner M, Eriksson L, Scholz J et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol 2010; 27: 874–81. DOI: http://dx.doi.org/10.1097/eja.0b013e32833d56b7
37. Esnaola NF, Cole DJ. Perioperative normothermia during major surgery: is it important? Adv Surg 2011; 45: 249–63. DOI: http://dx.doi.org/10.1016/j.yasu.2011.03. 007
38. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and Surgery. Anaesthesia 2013, 68: 179–89. DOI: http://dx.doi.org/ 10.1111/anae.12067
39. King PM, Blazeby JM, Ewings P et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006; 93: 300–8. DOI: http://dx.doi.org/10.1002/bjs.5216
40. Almada CP, Martins FA, Tardelli MA, Amaral JL. Time of extubation and postoperative outcome after thoracotomy. Revisita Associacao Medica Brasiliera 2007; 53: 209–12. DOI: http://dx.doi.org/10.1590/s0104-42302007000300016
41. Lassen K, Kjaeve J, Fetveit T et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg 2008; 247: 721–9. DOI: http://dx.doi.org/10.1097/sla. 0b013e31815cca68
42. Satherley LK, Luckraz H, Rammohan KS et al. Routine placement of an intercostal chest drain during video-assisted thoracoscopic surgical lung biopsy unnecessarily prolongs in-hospital length of stay in selected patients. Eur J Cardio-thoracic Surg 2009; 36: 737–40. DOI: http://dx.doi.org/10.1016/j.ejcts.2009.04.067
43. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 3: CD004929. DOI: http://dx.doi.org/ 10.1002/14651858.cd004929
44. Brower RG. Consequences of bed rest. Crit Care Med 2009; 37: 422–8. DOI: http://dx.doi.org/10.1097/ccm.0b013e3181b6e30a
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1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630e41. DOI: http://dx.doi.org/10.1016/S0002-9610(02)00866-8
2. Pearse RM, Harrison DA, James P et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006; 10: R81. DOI: 10.1186/cc4928
3. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991; 78: 355–60. DOI: http://dx.doi.org/10.1002/bjs.1800780327
4. Lee TH, Marcantonio ER, Mangione CM et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043–9. DOI: http://dx.doi.org/10.1161/01.cir.100.10.1043
5. Kheterpal S, Tremper KK, Heung M et al. Development and validation of an acute kidneyinjury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 2009; 110: 505–15. DOI: http://dx.doi. org/10.1097/aln. 0b013e3181979440
6. Fleisher LA, Beckman JA, Brown KA et al. AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2007; 116: e418–99. DOI: http://dx.doi.org/10.3410/ f.1098966.555143
7. Moriello C, Mayo NE, Feldman L, Carli F. Validating the six-minute walk test as a measure of recovery after elective colon resection surgery. Arch Phys Med Rehabil 2008; 89: 1083–9. DOI:http://dx.doi.org/10.1016/j.apmr.2007.11.031
8. Older P, Smith R, Hall A, French C. Preoperative cardiopulmonary risk assessment by cardiopulmonary exercise testing. Crit Care Resusc 2000; 2: 198–208. DOI: http://dx.doi.org/10.1017/cbo9780511544521.002
9. Houts PS, Doak CC et al. The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence. Patient Education Counseling 2006; 61 (Issue 2): 173–90. DOI: http://dx.doi.org/10.1016/j.pec. 2005.05.004
10. Mendelson CL. The aspiration of stomach contents into the lungs during obstetrics anesthesia. Am J Obstet Gynecol 1946; 52: 191–205. DOI: http://dx.doi.org/ 10.1097/00006254-194612000-00024
11. Brady M, Kinn S, Stuart P. Perioperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; 4: CD004423. DOI: http://dx.doi.org/10.1002/14651858.cd004423
12. Smith I, Kranke P, Murat I et al. European Society of Anaesthesiology. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28: 556–69. DOI: http://dx.doi.org/10.1097/eja. 0b013e3283495ba1
13. Awad S, Varadhan KK, Ljungqvist O et al. A metha-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr 2013; 32: 34–44. DOI: http://dx.doi.org/10.1016/j.clnu.2012.10.011
14. Smith MD, McCall L, Plank L. Preoperative carbohydrate treatment for enchansing recovery after elective surgery. Cochrane Database Syst Rev 2014; 8: CD009161. DOI: http://dx.doi.org/10.1002/14651858.cd009161.pub2
15. Bluman LG, Mosca L, Newman N et al. Preoperative smoking habits and postoperative pulmonary complications. Chest 1998; 113: 883–9. DOI: http://dx.doi.org/ 10.1378/chest.113.4.883
16. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003; 238: 1–5. DOI: http://dx.doi.org/10.1097/01.sla.0000074980.39700.31
17. Lindstrom D, Sadr AO, Wladis A et al. Effects of a perioperative smoking сessation intervention on postoperative complications: a randomized trial. Ann Surg 2008; 248: 739–45. DOI: http://dx.doi.org/10.1097/sla.0b013e3181889d0d
18. Holte K, Nielsen KG, Madsen JL et al. Physiologic effects of bowel reparation. Dis Colon Rectum 2004; 47: 1397–402. DOI: http://dx.doi.org/10.1007/s10350-004-0592-1
19. Guenaga KF, Matos D, Castro AA et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005; 1: CD001544. DOI: http://dx.doi.org/10.1002/14651858.cd001544
20. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and metaanalysis. Int J Colorectal Dis 2011; 27: 803–10. DOI: http://dx.doi.org/10.1007/s00384-011-1361-y
21. Spyropoulos AC, Brotman DJ, Amin AN et al. Prevention of venous thromboembolism in the cancer surgery patient. leveClin J Med 2008; 75 (Suppl. 3): S17–S26. DOI: http://dx.doi.org/10.3949/ccjm.75.suppl_3.s17
22. National Institute for Health and Clinical Excellence. Venous Thromboembolism: Reducing the Risk. London: NICE. Clin Guidance 2010; 92. DOI: http://dx.doi.org/ 10.1136/bmj.c95
23. Kakkos SK, Caprini JA, Geroulakos G et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev 2008; 4: CD005258. DOI: http://dx.doi.org/10.1002/14651858.cd005258
24. Rasmussen MS, Jorgensen LN, Wille-Jorgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2009; 1: CD004318. DOI: http://dx.doi.org/10.1002/ 14651858. cd004318.pub2
25. Savel'ev V.S., Gel'fand B.R., Iakovlev S.V. i dr. Rossiiskie natsional'nye rekomendatsii. Strategiia i taktika primeneniia antimikrobnykh sredstv v lechebnykh uchrezhdeniiakh Rossii. M.: GEOTAR-Media, 2012. DOI: http://www.labtechperm.ru/spex/47/ [in Russian]
26. Chang SH, Krupnick AS. Perioperative antibiotics in thoracic surgery. Thoracic Surg Clin 2012; 22: 35–45. DOI: http://dx.doi.org/10.1016/j.thorsurg.2011.08.012
27. Lassen K, Coolsen M, Slim K et al. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2013; 37: 240–58. DOI: http://dx.doi.org/10.1007/s00268-012-1771-1
28. Caumo W, Hidalgo MP, Schmidt AP et al. Effect of preoperative anxiolysis on postoperative pain response in patients undergoing total abdominal hysterectomy. Anaesthesia 2002; 57: 740–6. DOI: http://dx.doi.org/10.1046/j.1365-2044.2002.02690.x
29. Moiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia. Anesthesiology 2002; 96: 725–41. DOI: http://dx.doi.org/10.1097/00000542-200203000-00032
30. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology 2010; 112: 220–5. DOI: http://dx.doi.org/10.1097/ aln.0b013e3181c6316e
31. Popping DM, Elia N, Van Aken HK et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259: 1056–67. DOI: http://dx.doi.org/10.1097/ sla.0000000000000237
32. Feldheiser A, Aziz O, Baldini G et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60 (3): 289–334. DOI: http://dx.doi.org/10.1111/aas.12651
33. Yates DR, Davies SJ, Milner HE, Wilson RJ. Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery. Br J Anaesth 2014; 112: 281–9. DOI: http://dx.doi.org/10.1093/bja/aet307
34. Murphy GS, Szokol JW, Marymont JH et al. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology 2008; 109: 389–98. DOI: http://dx.doi.org/10.1097/aln.0b013e318182af3b
35. Geldner G, Niskanen M, Laurila P et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67: 991–8. DOI: http://dx.doi.org/10.1111/j.1365-2044.2012.07197.x
36. Blobner M, Eriksson L, Scholz J et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol 2010; 27: 874–81. DOI: http://dx.doi.org/10.1097/eja.0b013e32833d56b7
37. Esnaola NF, Cole DJ. Perioperative normothermia during major surgery: is it important? Adv Surg 2011; 45: 249–63. DOI: http://dx.doi.org/10.1016/j.yasu.2011.03. 007
38. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and Surgery. Anaesthesia 2013, 68: 179–89. DOI: http://dx.doi.org/ 10.1111/anae.12067
39. King PM, Blazeby JM, Ewings P et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006; 93: 300–8. DOI: http://dx.doi.org/10.1002/bjs.5216
40. Almada CP, Martins FA, Tardelli MA, Amaral JL. Time of extubation and postoperative outcome after thoracotomy. Revisita Associacao Medica Brasiliera 2007; 53: 209–12. DOI: http://dx.doi.org/10.1590/s0104-42302007000300016
41. Lassen K, Kjaeve J, Fetveit T et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg 2008; 247: 721–9. DOI: http://dx.doi.org/10.1097/sla. 0b013e31815cca68
42. Satherley LK, Luckraz H, Rammohan KS et al. Routine placement of an intercostal chest drain during video-assisted thoracoscopic surgical lung biopsy unnecessarily prolongs in-hospital length of stay in selected patients. Eur J Cardio-thoracic Surg 2009; 36: 737–40. DOI: http://dx.doi.org/10.1016/j.ejcts.2009.04.067
43. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 3: CD004929. DOI: http://dx.doi.org/ 10.1002/14651858.cd004929
44. Brower RG. Consequences of bed rest. Crit Care Med 2009; 37: 422–8. DOI: http://dx.doi.org/10.1097/ccm.0b013e3181b6e30a
A.V.Vishnevsky Institute of Surgery of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Bol'shaia Serpukhovskaia, d. 27
*esakov@ixv.ru