Manejo anestésico del paciente sometido a cirugía de resección de osteosarcoma

Abstract

In Uruguay, after cardiovascular diseases, cancer ranks second as a cause of death. According to official data from the Ministry of Public Health in 2017, 24.6% of deaths were due to this disease. In our specialty, there is great concern about the evolutionary consequences of neoplastic disease related to the surgical anesthetic act, conceptualized from the length of the perioperative period. We consider necessary the inclusion of protocols for neoplastic surgery that favor recovery and evolution in the short and long term. This implies establishing anesthesiological strategies aimed at preserving immunity, by reducing psychological and surgical stress, adequate pharmacological selection, management of the internal environment and analgesia. For these reasons, it is important to establish the implementation of perioperative plans that reduce psychosomatic aggression, which in addition to medical stability, provide quality analgesia, with postoperative well-being that allow rest and recovery. Great advances have been made in tumor resection surgical techniques such as neoadjuvant and adjuvant polychemotherapy techniques, however, tumor recurrence rates have not been reduced as would be desired. Beyond the natural malignancy of the underlying pathology, it is inferred that surgical stress with a long and torpid perioperative period favors tumor recurrence. Hence our special interest in these communications related to patients in the search for solutions that improve their vital prognosis. Based on current evidence, it can be affirmed that the decrease in opiate consumption, especially the decrease in the need for Morphine, may favor better prognoses; maintaining the antimetastatic immune response in a period of special protumoral susceptibility such as the perioperative period. We therefore propose the use of analgesic / anesthetic techniques supported on the basis of regional anesthetic blocks prior to surgical aggression, complemented with the administration of Propofol, NSAIDs and β-blockers during the intraoperative period, through the presentation of 2 clinical cases of patients with osteosarcoma of knee.

Anesthesia Management to Improve Outcomes

“…During surgical procedures, there are multiple factors related to surgery that determine secondary depression of immunity. Within these, we find psychological stress, tissue damage typical of the surgical act, pain, hypothermia, blood transfusion and factors related to the drugs used that generate alterations in immunity [3][4][5].…”

“…Tumor manipulation during resection may result in a "spill" of tumor cells into the bloodstream and lymphatic vessels. On the other hand, after surgery, the balance between pro-and antiangiogenic factors is shifted towards angiogenesis to facilitate tissue healing, which may favor tumor recurrence, metastasis formation, and activation of latent micrometastases [5]. The implantation of distant metastases focuses on the so-called "seed and soil" hypothesis; (seed and fertile land) described more than 100 years ago.…”

“…Anesthesia alters the functions of immune cells, including neutrophils, macrophages, dendritic cells, T lymphocytes, and NK cells [33]. Some of the drugs frequently used in general anesthesia have an inhibitory effect on naturalkiller cell-mediated immunity, particularly morphine, ketamine, thiopental, and inhalational anesthetics [24], on the other hand, it would seem that propofol, nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthetics have shown promising results (Table 1) [3][4][5].…”

“…propofol, in addition to adjuvant regional techniques according to the procedure to be performed (Table 2) [5]. We propose the example of a healthy young patient who undergoes resection surgery for osteosarcoma of the knee.…”

“…Anesthetic drugs can induce changes in cell pathophysiology such as cell proliferation, angiogenesis, and apoptosis, and may be determinant in the progression of oncological disease in patients. This is why we are interested in identifying the main perioperative factors that play a role in tumor recurrence in cancer patients who undergo surgery; as well as evaluating which drugs may or may not be beneficial in the perioperative period [3][4][5].…”