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Carbonell BB, Zingg T, Matter M, Joliat GR, Martin D, Pascual M, Demartines N, Golshayan D, Cano L, Labgaa I. Assessing the perioperative gain of weight (Δweight) as a determinant of morbidity after kidney transplantation: a retrospective exploratory study. Sci Rep 2024; 14:13384. [PMID: 38862590 PMCID: PMC11167037 DOI: 10.1038/s41598-024-63950-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024] Open
Abstract
Kidney transplantation (KT) is associated with a substantial risk of postoperative complications (POC) for which performant predictors are lacking. Data showed that a perioperative gain of weight (ΔWeight) was associated with higher risk of POC, but it remains unexplored in KT. This retrospective study aimed to investigate the association between ΔWeight and POC after KT. ΔWeight was calculated on postoperative day (POD) 2. POC were graded according to the Dindo-Clavien classification. Primary endpoint was overall POC. A total of 242 patients were included and 174 (71.9%) complications were reported. Patients showed a rapid gain of weight after KT. Mean ΔWeight was 7.83 kg (± 3.20) compared to 5.3 kg (± 3.56) in patients with and without complication, respectively (p = 0.0005). ΔWeight showed an accuracy of 0.74 for overall POC. A cut-off of 8.5 kg was determined. ΔWeight ≥ 8.5 kg was identified as an independent predictor of overall POC on multivariable analysis (OR 2.04; 95% CI 1.08-3.84; p = 0.025). ΔWeight ≥ 8.5 kg appeared as an independent predictor of POC after KT. These results stress the need to monitor weight in KT and to further investigate this surrogate with future studies assessing its clinical relevance.
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Affiliation(s)
- Beatriz Barberá Carbonell
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maurice Matter
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland
| | - David Martin
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Manuel Pascual
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Dela Golshayan
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Luis Cano
- Nutrition Metabolism and Cancer, INSERM, University of Rennes, INRAE, CHU Pontchaillou, UMR 1241 NUMECAN, Rennes, France
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.
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Deslarzes P, Jurt J, Larson DW, Blanc C, Hübner M, Grass F. Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice. J Clin Med 2024; 13:801. [PMID: 38337495 PMCID: PMC10856154 DOI: 10.3390/jcm13030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.
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Affiliation(s)
- Philip Deslarzes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Jonas Jurt
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - David W. Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA;
| | - Catherine Blanc
- Department of Anesthesiology, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland;
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), 1005 Lausanne, Switzerland; (P.D.); (J.J.); (M.H.)
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Egger EK, Merker F, Ralser DJ, Marinova M, Vilz TO, Matthaei H, Hilbert T, Mustea A. Postoperative paralytic ileus following debulking surgery in ovarian cancer patients. Front Surg 2022; 9:976497. [PMID: 36090332 PMCID: PMC9448895 DOI: 10.3389/fsurg.2022.976497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
Aim This study aims to evaluate the incidence of postoperative ileus (POI) following cytoreductive surgery in epithelial ovarian cancer (EOC) patients and its impact on anastomotic leakage occurrence and postoperative complications. Methods A total of 357 surgeries were performed on 346 ovarian cancer patients between 1/2010 and 12/2020 at our institution. The postoperative course regarding paralytic ileus, anastomotic leakage, and postoperative complications was analyzed by Fisher's exact test and through ordinal logistic regression. Results A total of 233 patients (65.3%) returned to normal gastrointestinal functions within 3 days after surgery. A total of 123 patients (34.5%) developed POI. There were 199 anastomoses in 165 patients and 24 leakages (12.1%). Postoperative antibiotics (p 0.001), stoma creation (p 0.0001), and early start of laxatives (p 0.0048) significantly decreased POI, while anastomoses in general (p 0.0465) and especially low anastomoses (p 0.0143) showed increased POI rates. Intraoperative positive fluid excess >5,000 cc was associated with a higher risk for POI (p 0.0063), anastomotic leakage (p 0.0254), and severe complications (p 0.0012). Conclusion Postoperative antibiotics, an early start with laxatives, and stoma creation were associated with reduced POI rates. Patients with anastomoses showed an increased risk for POI. Severe complications, anastomotic leakages, and POI were more common in the case of intraoperative fluid balance exceeding 5,000 cc.
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Affiliation(s)
- Eva K. Egger
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
- Correspondence: Eva K. Egger
| | - Freya Merker
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Damian J. Ralser
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Milka Marinova
- Department of Interventional and Diagnostic Radiology, University Hospital Bonn, Bonn, Germany
| | - Tim O. Vilz
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
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4
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Greenberg AL, Kelly YM, Sarin A, Varma MG. Proof-of-concept for intervention to prevent post-operative ileus in patients undergoing ileostomy formation. Perioper Med (Lond) 2022; 11:25. [PMID: 35818058 PMCID: PMC9275170 DOI: 10.1186/s13741-022-00257-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background Preventing post-operative ileus (POI) is important given its associated morbidity and increased cost of care. The authors’ prior work showed that POI in patients with newly created ileostomies is associated with a post-operative day (POD) 2 net fluid balance of > + 800 mL. The purpose of this study was to conduct an initial assessment of the efficacy of a pilot intervention. Methods This is a single-institution, pre–post-intervention, proof-of-concept study conducted on the Colorectal Surgery service at the University of California, San Francisco. The study included 58 procedures with ileostomy formation by board-certified colorectal surgeons between August 13, 2020 and June 1, 2021. The intervention included three adjustments to the standard Enhanced Recovery After Surgery protocol: addition of diuresis, delay in advancement to solid food, and earlier stoma intubation. Demographics, intraoperative factors, post-operative fluid balance, and outcomes (POI, post-procedure length of stay [LOS], hospitalization cost, and re-admissions) were compared between patients pre- and post-intervention. Results Eight (13.8%) of the 58 procedures in the intervention period were associated with POI vs. a baseline POI rate of 32.6% (p = 0.004). Compared to patients without intervention, those with intervention had 67% less odds of POI (OR 0.33, 95% CI 0.15–0.73, p = 0.01). This difference remained significant when adjusted for age, gender, body mass index, procedure duration, and operative approach (adjusted OR 0.32, 95% CI 0.14–0.72, p = 0.01). Average POD2 stoma output was 0.3 L greater (1.1 L vs. 0.8L; p < 0.001) and net fluid balance was 1.8 L lower (+ 0.3 L vs. + 2.1 L; p < 0.00001) for these 58 cases. Average post-procedure LOS was 1.9 days lower (5.3 vs. 7.2 days, p < 0.001) and direct cost was $5561 lower ($21,652 vs. $27,213, p = 0.004), with no difference in 30-day readmissions (p = 0.43). Conclusions This pilot intervention shows promise for reduction in POI in patients with newly created ileostomies. Additional assessment is needed to confirm these initial findings.
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Affiliation(s)
- Anya L Greenberg
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Yvonne M Kelly
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ankit Sarin
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Madhulika G Varma
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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5
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de Gaay Fortman DPE, Kroon HM, Bedrikovetski S, Fitzsimmons TR, Dudi-Venkata NN, Sammour T. A snapshot of intraoperative conditions to predict prolonged postoperative ileus after colorectal surgery. ANZ J Surg 2022; 92:2199-2206. [PMID: 35579059 DOI: 10.1111/ans.17784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/28/2022] [Accepted: 04/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The cause of prolonged postoperative ileus (PPOI) is multifactorial. The influence of preoperative factors on PPOI has been well documented, but little is known about the impact of intraoperative conditions. The aim of this study was to investigate the influence of intraoperative factors on PPOI in patients undergoing colorectal surgery. METHODS The LekCheck study database of the Colorectal Unit at the Royal Adelaide Hospital was analysed. Per patient, over 60 data points were prospectively collected between March 2018 and July 2020. Intraoperative data were collected in theatre during a one-off snapshot measure. Univariate and multivariable logistic regression analyses were performed. RESULTS Data of 336 patients were included. The median age was 66 years and 58.3% were male. Ninety-three patients (27.7%) developed PPOI. Univariate analysis identified the following intraoperative variables as risk-factors of PPOI: greater volumes of intraoperative IV fluid administration (464 versus 415 mL/h for those without PPOI; p = 0.04), side-to-side anastomosis orientation (53.8 versus 41.2%; p = 0.04) and increased perioperative opioid use (6.73 versus 4.11 mg/kg morphine equivalents for patients with and without PPOI, respectively; p = 0.02). Upon multivariable analysis, increased perioperative opioid use remained significant (p = 0.05), as well as the preoperative factors anticoagulation use (p = 0.04) and higher levels of serum total protein (p = 0.02). CONCLUSION This study suggests that intraoperative factors may also contribute to the development of PPOI, but this could not be confirmed in the multivariate analysis. Further studies including larger patient numbers will be required to determine the impact of intraoperative conditions on the development of PPOI.
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Affiliation(s)
- Duveke P E de Gaay Fortman
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tracy R Fitzsimmons
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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6
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Liu Z, Fang L, Lv L, Niu Z, Hou L, Chen D, Zhou Y, Guo D. Self-administered succus entericus reinfusion before ileostomy closure improves short-term outcomes. BMC Surg 2021; 21:440. [PMID: 34961502 PMCID: PMC8713408 DOI: 10.1186/s12893-021-01444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The study aims to assess whether reinfusion of succus entericus prior to ileostomy closure can decrease postoperative length of stay and ameliorate low anterior resection score. METHODS This study is a retrospective analysis based on prospectively collected data. Patients were screened from May 2016 to November 2019. A total of 30 patients who underwent reinfusion with succus entericus (SER) were enrolled in the SER group and 42 patients without SER were enrolled in the non-SER group. RESULTS There was no significant difference in the incidence of postoperative ileus between succus entericus reinfusion (SER) group and the control group. Time to first passage of flatus or stool after surgery in the SER group (27.9 ± 6.02 h) is significantly shorter than the control group (32.3 ± 6.26, hours p = 0.004). Compared with the control group (5.52 (4.0-7.0) days), postoperative length of stay in the SER group was 4.90 (3.0-7.0)days (p = 0.009). As for low anterior resection score(LARS), the SER group had a lower score 1 week after discharge than the control group (p = 0.034). However, 1 month after discharge, the LARS in the two groups had no significant difference. CONCLUSIONS Self-administered succus entericus reinfusion is a feasible prehabilitation management for outpatients and can improve better outcomes. Compared with non-reinfusion group, succus enterius reinfusion group displays significantly shorter time for gastrointestinal function recovery and postoperative hospital stay without increasing complication, and it can bring better quality of life in a short term.
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Affiliation(s)
- Zhen Liu
- Department of Emergency Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Liang Fang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Liang Lv
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Zhaojian Niu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Litao Hou
- Department of General Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Dong Chen
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Yanbing Zhou
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China
| | - Dong Guo
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Qingdao University, No.16 Jiangsu Rd, Qingdao, 266000, Shandong, China.
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Greenberg AL, Kelly YM, McKay RE, Varma MG, Sarin A. Risk factors and outcomes associated with postoperative ileus following ileostomy formation: a retrospective study. Perioper Med (Lond) 2021; 10:55. [PMID: 34895339 PMCID: PMC8667388 DOI: 10.1186/s13741-021-00226-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/16/2021] [Indexed: 02/06/2023] Open
Abstract
Background Postoperative ileus (POI) is associated with increased patient discomfort, length of stay (LOS), and healthcare cost. There is a paucity of literature examining POI in patients who have an ileostomy formed at the time of surgery. We aimed to identify risk factors for and outcomes associated with POI following ileostomy formation. Methods We included 261 consecutive non-emergent cases that included formation of an ileostomy by a board-certified colorectal surgeon at our institution from July 1, 2015, to June 30, 2020. Demographic, clinical, and intraoperative factors associated with increased odds of POI were evaluated. Post-procedure LOS, hospitalization cost, and re-admissions between patients with and without POI were compared. Results Out of 261 cases, 85 (32.6%) were associated with POI. Patients with POI had significantly higher body mass index (BMI) than those without POI (26.6 kg/m2 vs. 24.8kg/m2; p = 0.01). Intraoperatively, patients with POI had significantly longer procedure duration than those without POI (313 min vs. 279 min; p = 0.02). Patients with POI had a significantly higher net fluid balance at postoperative day (POD) 2 than those without POI (+ 2.65 L vs. + 1.80 L; p = 0.004), with POD2 fluid balance greater than + 807 mL (determined as the maximum Youden index for sensitivity over 80%) associated with a higher rate of POI (p = 0.006). This difference remained significant when adjusted for age, gender, BMI, pre-operative opioid use, procedure duration, and operative approach (p = 0.01). Patients with POI had significantly longer LOS (11.40 days vs. 5.12 days; p < 0.001) and direct cost of hospitalization ($38K vs. $22K; p < 0.001). Conclusions Minimizing fluid overload, particularly in the first 48 h after surgery, may be a strategy to reduce POI in patients undergoing ileostomy formation, and thus decrease postoperative LOS and hospitalization cost. Fluid restriction, diuresis, and changes in diet advancement or early stoma intubation should be considered measures that may improve outcomes and should be studied more intensively.
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Affiliation(s)
- Anya L Greenberg
- School of Medicine, University of California, San Francisco, 513 Parnassus Ave #S-245, San Francisco, CA, 94143, USA
| | - Yvonne M Kelly
- Department of Surgery, University of California, San Francisco, 513 Parnassus Ave #S-321, San Francisco, CA, 94143, USA
| | - Rachel E McKay
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Madhulika G Varma
- Department of Surgery, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Ankit Sarin
- Department of Surgery, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
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8
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Guo D, Jiang K, Hong J, Zhang M, Shi Y, Zhou B. Association between vedolizumab and postoperative complications in IBD: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:2081-2092. [PMID: 34467414 DOI: 10.1007/s00384-021-04017-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The effect of preoperative vedolizumab (VDZ) therapy on postoperative complications in inflammatory bowel disease (IBD) patients is still controversial. This meta-analysis aims to review postoperative complications of IBD patients who preoperatively received VDZ. METHODS A meta-analysis of the available literature was performed. Studies of IBD patients who received VDZ and non-VDZ therapy (including anti-TNF-α agents, non-biological therapy, other biological agents, ustekinumab, and placebo) before surgery were included. Primary outcomes included overall complications, infectious complications, and non-infectious complications. RESULTS Twelve studies with 1925 IBD patients were enrolled, among which 709 patients received VDZ treatment. The results show that, compared with non-VDZ treatment, there is no significant difference in the incidence of overall complications (OR = 1.25, p = 0.43) for adult IBD patients treated with VDZ preoperatively, the incidence of infectious complications (OR = 0.49, p = 0.001) decreases, but the risks of all surgical site infection (SSI) (Crohn's disease (CD): OR = 2.97, p < 0.001), superficial surgical site infection (sSSI) (OR = 2.24, p = 0.02), and ileus (OR = 2.16, p < 0.001) increase. The risk of mucocutaneous separation (MCS) (OR = 4.69, p = 0.03) with VDZ is also higher than non-VDZ. Two studies involved pediatric patients and showed no difference in ileus (OR = 0.55, p = 0.55). CONCLUSIONS Overall, compared with non-VDZ treatment, preoperative use of VDZ is relatively safer in adult IBD patients, which does not increase the risk of overall postoperative complications and reduces the occurrence of infectious complications. But, it increases the risk of all SSI and sSSI in infectious complications and the incidence of ileus and MCS in non-infectious complications. Due to lack of sufficient data, the safety of VDZ in pediatric patients is uncertain and requires further study.
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Affiliation(s)
- Daxin Guo
- Department of Gastroenterology, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Ke Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengting Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yetan Shi
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Bin Zhou
- Department of General Surgery, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
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9
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Koch KE, Hahn A, Hart A, Kahl A, Charlton M, Kapadia MR, Hrabe JE, Cromwell JW, Hassan I, Gribovskaja-Rupp I. Male sex, ostomy, infection, and intravenous fluids are associated with increased risk of postoperative ileus in elective colorectal surgery. Surgery 2021; 170:1325-1330. [PMID: 34210525 DOI: 10.1016/j.surg.2021.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative ileus is a common and costly complication after elective colorectal surgery. Effects of intravenous fluid administration remain controversial, and the effect of ostomy construction has not been fully evaluated. Various restrictive intravenous fluid protocols may adversely affect renal function. We aimed to investigate the impact of intestinal reconstruction and intravenous fluid on ileus and renal function after colorectal resection under an enhanced recovery protocol. METHODS A retrospective study of a prospectively maintained institutional database for a tertiary academic medical center following National Surgical Quality Improvement Program standards was reviewed, analyzing elective colorectal resections performed under enhanced recovery protocol from 2015 to 2018. Postoperative ileus was defined as nasogastric decompression, nil per os >3 days postoperatively, or nasogastric tube insertion. Patients with and without ileus were compared. Intravenous fluid and different anastomoses and ostomies were investigated. Acute kidney injury was a secondary outcome, due to the potential of renal damage with restriction of intravenous fluid volume during and after surgery and controversy in current literature in this matter. RESULTS Postoperative ileus occurred in 18.5% of patients (n = 464). Male sex (odds ratio 1.97, 95% confidence interval 1.12-3.52) and postoperative infection (odds ratio 2.13, 95% confidence interval 1.03-4.35) were associated with ileus. Compared to colorectal anastomosis, ileostomy/ileorectal anastomosis had the highest risk of ileus (odds ratio 4.9, 95% confidence interval 2.33-11.3), colostomy second highest (odds ratio 3.3, 95% confidence interval 1.35-8.39), while ileocolic anastomosis did not significantly differ (odds ratio 2.06, 95% confidence interval 0.69-5.85) on multivariate analysis. Each liter of intravenous fluid within the first 72 hours significantly correlated with postoperative ileus (odds ratio 1.41, 95% confidence interval 1.27-1.59). Rates of acute kidney injury did not differ (P = .18). CONCLUSION Each additional liter of intravenous fluid given in the first 72 hours increased the risk of postoperative ileus 1.4-fold. There is substantially higher risk of ileus with male sex, infection, ileostomy/ileorectal anastomosis, and colostomy. Judicious use of intravenous fluid, as described in our enhanced recovery protocol, is not detrimental for renal function in the setting of normal baseline.
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Affiliation(s)
- Kelsey E Koch
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Amy Hahn
- College of Public Health, University of Iowa, Iowa City, IA
| | - Alexander Hart
- College of Public Health, University of Iowa, Iowa City, IA
| | - Amanda Kahl
- College of Public Health, Iowa Cancer Registry, University of Iowa, Iowa City, IA
| | - Mary Charlton
- College of Public Health, University of Iowa, Iowa City, IA
| | - Muneera R Kapadia
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - John W Cromwell
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Imran Hassan
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
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Shim JS, Noh TI, Ku JH, Lee S, Kwon TG, Kim TH, Jeon SH, Lee SH, Nam JK, Kim WS, Jeong BC, Lee JY, Hong SH, Rha KH, Han WK, Ham WS, Lee YG, Lee YS, Park SY, Yoon YE, Kang SG, Oh JJ, Kang SH. Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy. Sci Rep 2021; 11:10522. [PMID: 34006918 PMCID: PMC8131600 DOI: 10.1038/s41598-021-89806-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/29/2021] [Indexed: 01/15/2023] Open
Abstract
This study aimed to investigate the effect of intraoperative fluid volume on the postoperative ileus (POI) recovery period. A retrospective review of the Korean robot-assisted radical cystectomy database identified 718 patients who underwent robot-assisted radical cystectomy (RARC). Regression analyses were performed to identify the associations between the amount of intraoperative fluid administration (crystalloid/colloid/total), POI period (time to flatus/bowel movements), and length of hospital stay (LOS) after adjusting for covariates. In addition, we analyzed the risk factors for gastrointestinal complications and prolonged POI using a logistic regression model. An increasing volume of the administered crystalloid/total fluid was associated with prolonged POI (crystalloid R2 = 0.0725 and P < 0.0001; total amount R2 = 0.0812 and P < 0.0001), and the total fluid volume was positively associated with the LOS (R2 = 0.099 and P < 0.0001). The crystalloid amount was a risk factor for prolonged POI (P < 0.001; odds ratio, 1.361; 95% confidence interval, 1.133–1.641; P < 0.001). In the context of RARC, increased intravenous fluids are associated with prolonged POI and longer LOS.
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Affiliation(s)
- Ji Sung Shim
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Tae Il Noh
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Sangchul Lee
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Gyun Kwon
- Department of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Tae-Hwan Kim
- Department of Urology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Hyun Jeon
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Hyup Lee
- Department of Urology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jong Kil Nam
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wan Seok Kim
- Department of Urology, College of Medicine, Busan Paik Hospital, Inje University, Busan, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Youl Lee
- Department of Urology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung Hoo Hong
- Department of Urology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Kyu Han
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sik Ham
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Lee
- Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
| | - Yong Seong Lee
- Department of Urology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sung Yul Park
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
| | - Young Eun Yoon
- Department of Urology, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Gu Kang
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea
| | - Jong Jin Oh
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea. .,Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Seok Ho Kang
- Department of Urology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul, 02841, Korea.
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11
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Aktaş A, Kayaalp C, Ateş M, Dirican A. Risk factors for postoperative ileus following loop ileostomy closure. Turk J Surg 2020; 36:333-339. [PMID: 33778391 DOI: 10.47717/turkjsurg.2020.4911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 02/04/2023]
Abstract
Objectives The most common intra-abdominal complication following loop ileostomy closure (LIC) is postoperative ileus (POI). The aim of the study was to determine the risk factors of POI development following LIC and make recommendations for its prevention. Material and Methods In this study, patients having undergone LIC with peristomal incision following distal colorectal surgery were included. Clavien-Dindo classification was used to evaluate postoperative complications. POI and postoperative leakage were defined based on clinical and radiological criteria. The Centers for Disease Control and Prevention 2017 criteria were used to diagnose surgical site infection (SSI). Postoperative bleeding was diagnosed one day after surgery if there was a >2 g/dL or ≥15% decrease in the hemoglobin level. Results Seventy-nine patients were included into the study. In nine of the patients POI developed, six had SSI, five had postoperative bleeding, and two had anastomosis leakage. In the univariate analysis; age <60 years (p= 0.02), presence of comorbidity (p= 0.007), using an open technique in the first surgery (p= 0.02), performing total colectomy in the first surgery (p= 0.048), performing hand-sewn anastomosis of LIC (p= 0.01), and postoperative blood transfusion (p= 0.04) were found to be risk factors for POI. Performing hand-sewn anastomosis of LIC (p= 0.03) and using an open technique in the first surgery (p= 0.03) were found to be independent variables for POI risk. Conclusion Using an open technique in the first surgery and performing a hand-sewn anastomosis of LIC may increase POI.
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Affiliation(s)
- Aydın Aktaş
- Department of General Surgery, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
| | - Cüneyt Kayaalp
- Department of Gastointestinal Surgery, İnönü University, School of Medicine, Malatya, Turkey
| | - Mustafa Ateş
- Department of General Surgery, İnönü University, School of Medicine, Malatya, Turkey
| | - Abuzer Dirican
- Department of General Surgery, İnönü University, School of Medicine, Malatya, Turkey
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12
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Butti F, Pache B, Winiker M, Grass F, Demartines N, Hübner M. Correlation of postoperative fluid balance and weight and their impact on outcomes. Langenbecks Arch Surg 2020; 405:1191-1200. [PMID: 33047238 PMCID: PMC7686193 DOI: 10.1007/s00423-020-02004-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes. METHODS All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0-3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression. RESULTS One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0-1-2-3 was 1850 (IQR 1020-2540) mL, 2890 (IQR 1610-4000) mL, 3890 (IQR 2570-5380) mL, and 4000 (IQR 1890-5760) mL respectively, and median weight gain was 2.2 (IQR 0.3-4.3) kg, 3 (1.5-4.7) kg, and 3.9 (2.5-5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01-8.9, p = 0.049). CONCLUSION Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.
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Affiliation(s)
- Fabio Butti
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland
- Department of General Surgery, GHOL Nyon Hospital, Ch. Monastier 10, 1260, Nyon, Switzerland
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland
- Department of Gynaecology and Obstetrics, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Winiker
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland
- Department of General Surgery, HRC Rennaz Hospital, Route du Vieux Séquoia 20, 1847, Rennaz, Switzerland
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, CH - 1011, Lausanne, Switzerland.
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Gilgien J, Hübner M, Halkic N, Demartines N, Roulin D. Perioperative fluids and complications after pancreatoduodenectomy within an enhanced recovery pathway. Sci Rep 2020; 10:17898. [PMID: 33087844 PMCID: PMC7578041 DOI: 10.1038/s41598-020-74907-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/05/2020] [Indexed: 01/04/2023] Open
Abstract
Optimized fluid management is a key component of enhanced recovery (ERAS) pathways. Implementation is challenging for pancreatoduodenectomy (PD) and clear guidance is missing in the respective protocol. The aim of this retrospective study was to evaluate the influence of perioperative intravenous (IV) fluid administration on postoperative complications. 164 consecutive patients undergoing PD within ERAS between October 2012 and June 2017 were included. Perioperative IV fluid and morbidity (Clavien classification and comprehensive complication index (CCI)) were assessed. A threshold of more than 4400 ml IV fluid during the first 24 h could be identified to predict occurrence of complications (area under ROC curve 0.71), with a positive and negative predictive value of 93 and 23% respectively. More than 4400 ml intravenous fluids during the first 24 h was an independent predictor of overall postoperative complications (adjusted odds ratio 4.40, 95% CI 1.47–13.19; p value = 0.008). Patients receiving ≥ 4400 ml were associated with increased overall complications (94 vs 77%; p value < 0.001), especially pulmonary complications (31 vs 16%; p value = 0.037), as well as a higher median CCI (33.7 vs 26.2; p value 0.041). This threshold of 4400 ml intravenous fluid might be a useful indicator for the management following pancreatoduodenectomy.
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Affiliation(s)
- Jérôme Gilgien
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland.
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
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14
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Labgaa I, Joliat GR, Grass F, Jarrar G, Halkic N, Demartines N, Hübner M. Impact of postoperative weight gain on complications after liver surgery. HPB (Oxford) 2020; 22:744-749. [PMID: 31676254 DOI: 10.1016/j.hpb.2019.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 09/17/2019] [Accepted: 09/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent data has suggested that excessive perioperative weight gain may be associated with adverse outcomes after abdominal surgery, but this observation remains unexplored following liver surgery. The present study aimed to investigate the predictive value of perioperative weight fluctuation in predicting complications after liver surgery. METHODS Retrospective monocentric analysis of consecutive patients undergoing liver surgery between 2010 and 2016. Patients without available perioperative weight were excluded. Test variable was postoperative weight change (ΔWeight) measured on day 2 (POD2). Primary outcome was postoperative major morbidity according to Clavien classification (grades III-IV). Secondary outcomes were overall complications, Comprehensive Complication Index (CCI) and length of hospital stay (LoS). Area under the receiver operating characteristic curve (AUROC) and logistic regression with multivariable analysis were performed. RESULTS A total of 181 patients met the inclusion criteria. Major and overall postoperative complications were reported in 25 (14%) and 87 (48%) patients, respectively. On POD2, median ΔWeight was 2.6 Kg (IQR: 1.1-4.0). Patients with major complications showed increased ΔWeight of 4.2 Kg (IQR: 2.7-5.7), compared to 2.3 Kg (IQR: 0.9-3.7) in patients without major complications (p < 0.001). AUROC of ΔWeight for major complications was 0.74, determining an optimal cut-off of 3.5 Kg, which yielded a negative predictive value of 94%. Multivariable analysis identified ΔWeight ≥3.5 Kg as independent predictor of major complications (OR, 4.73; 95% CI, 1.51-14.80; p = 0.008). CONCLUSION ΔWeight ≥3.5 Kg was independently associated with major complications after liver surgery. Perioperative fluctuation of weight appears as an important predictor of adverse outcomes after liver surgery.
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Affiliation(s)
- Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland
| | | | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland; Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, United States
| | - Ghada Jarrar
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Switzerland
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15
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Goal-Directed vs Traditional Approach to Intraoperative Fluid Therapy during Open Major Bowel Surgery: Is There a Difference? Anesthesiol Res Pract 2019; 2019:3408940. [PMID: 31871449 PMCID: PMC6907038 DOI: 10.1155/2019/3408940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/22/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Optimum perioperative fluid therapy is important to improve the outcome of the surgical patient. This study prospectively compared goal-directed intraoperative fluid therapy with traditional fluid therapy in general surgical patients undergoing open major bowel surgery. Methodology Patients between 20 and 70 years of age, either gender, ASA I and II, and scheduled for elective open major bowel surgery were included in the study. Patients who underwent laparoscopic and other surgeries were excluded. After routine induction of general anaesthesia, the patients were randomised to either the control group (traditional fluid therapy), the FloTrac group (based on stroke volume variation), or the PVI group (based on pleth variability index). Fluid input and output, recovery characteristics, and complications were noted. Results 306 patients, with 102 in each group, were enrolled. Five patients (control (1), FloTrac (2), and PVI (2)) were inoperable and were excluded. Demographic data, ASA PS, anaesthetic technique, duration of surgery, and surgical procedures were comparable. The control group received significantly more crystalloids (3200 ml) than the FloTrac (2000 ml) and PVI groups (1875 ml), whereas infusion of colloids was higher in the FloTrac (400–700 ml) and PVI (200–500 ml) groups than in the control group (0–500 ml). The control group had significantly positive net fluid balance intraoperatively (2500 ml, 9 ml/kg/h) compared to the FloTrac (1515 ml, 5.4 ml/kg/h) and PVI (1420 ml, 6 ml/kg/h) groups. Days to ICU stay, HDU stay, return of bowel movement, oral intake, morbidity, duration of hospital stay, and survival rate were comparable. The total number of complications was not different between the three groups. Anastomotic leaks occurred more often in the Control group than in the others, but the numbers were small. Conclusions Use of goal-directed fluid management, either with FloTrac or pleth variability index results in a lower volume infusion and lower net fluid balance. However, the complication rate is similar to that of traditional fluid therapy. This trial is registered with CTRI/2018/04/013016.
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