The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy

Postoperative fluid therapy in enhanced recovery after surgery for pancreaticoduodenectomy

Backgrounds/Aims

Optimal intravenous fluid management during the perioperative period for patients undergoing pancreaticoduodenectomy (PD) within the framework of enhanced recovery after surgery (ERAS) is unclear. Studies have indicated that excessive total body salt and water can contribute to the development of oedema, leading to increased morbidity and extended hospital stays. This study aimed to assess the effects of an intravenous therapy regimen during postoperative day (POD) 0 to 2 in PD patients within ERAS.

Methods

A retrospective interventional cohort study was conducted, and it involved all PD patients before and after implementation of ERAS (2009-2017). In the ERAS group, a targeted maintenance fluid regimen of 20 mL/kg/day with a sodium requirement of 0.5 mmoL/kg/day was administered. Outcome measures included the mmol of sodium and chloride administered, length of stay, and morbidity (postoperative pancreatic fistula, POPF; acute kidney injury, AKI; ileus).

Results

The study included 169 patients, with a mean age of 64 ± 11.3 years. Following implementation of the intravenous fluid therapy protocol, there was a significant reduction in chloride and sodium loading. However, in the multivariable analysis, chloride administered (mmoL/kg) did not independently influence the length of stay; or rates of POPF, ileus, or AKI (p > 0.05).

Conclusions

The findings suggested that a postoperative intravenous fluid therapy regimen did not significantly impact morbidity. Notably, there was a trend towards reduced length of stay within an increasingly comorbid patient cohort. This targeted fluid regimen appears to be safe for PD patients within the ERAS program. Further prospective research is needed to explore this area.

A review of the current ERAS guidelines for liver resection, liver transplantation and pancreatoduodenectomy

In perioperative care after liver resection, transplantation and pancreatoduodenectomy, ERAS (Enhanced Recovery After Surgery) recommendations are based on the reducing invasiveness of procedures and the severity of the surgical stress, which results in decreasing complications and enhanced recovery. Recommendations for all three operations can be classified into five groups: recommended for all patients, recommended for special patient groups, rejected for all patients, controversial recommendations, specific recommendations for all three operations. Preoperative counselling and psychological support, nutritional support, smoking and alcohol cessation, pre- and intraoperative antibiotic prophylaxis, thrombosis prevention, limiting of preoperative hunger and thirst to 4 and 6 h, preoperative intaking carbohydrate rich drink, alcohol-based antiseptics for skin preparation, a goal-directed infusion therapy, providing normothermia, early removal of the drainage tube, glycemic control, dual antiemetic therapy, multimodal analgesia strategies, early oral feeding and activation, audit recommend for all patients. Postoperative antibiotic prophylaxis, enteral and parenteral nutrition, short-acting anxiolytics are recommended for individual patients. It is recommended to avoid Mercedes type incision, use of long-acting anxiolytics and postoperative nasogastric tube. The benefits of preoperative physical exercise, immunonutrition and probiotics are controversial. There are no specific recommendations for thoracic epidural anesthesia, preventing delayed gastric emptying and intestinal paresis in liver surgery.

Correlation Between Ultrasound-Measured Diameter and Blood Flow Velocity of the Internal Jugular Veins with the Preoperative Blood Volume in Elderly Patients

The study aimed to explore the correlation of the diameter and blood flow velocity of the internal jugular vein with the preoperative blood volume in elderly patients and to providence for rapid evaluation of preoperative blood volume with ultrasound in elderly patients. Thirty patients over 65 years old were recruited in the study. Patient’s central venous pressure (CVP) was recorded before anesthesia. The maximum diameter (Dmax) and the minimum diameter (Dmin) of the left internal jugular vein were measured by M type ultrasound and the respiratory variation index (RVI), defined as (Dmax − Dmin) / Dmax × 100%, was calculated. The maximum blood flow velocity (BVmax) and the minimum blood flow velocity (BVmin) were measured by Doppler ultrasound, and the blood flow variation index (BVI), defined as (BVmax − BVmin) / BVmax × 100%, was calculated. Then, each of the patients was given with 5 ml/kg crystalloid solution, and the relevant data were measured again and compared to that before infusion. The correlation between each measurement index and CVP, and their efficiency in predicting CVP > 6 mmHg were statistically evaluated. No matter before or after infusion, Dmax, Dmin, BVmax, and BVmin were positively correlated with CVP (Correlation is significant at the 0.01 level (2-tailed)); and RVI was negatively correlated with CVP (Correlation is significant at the 0.01 level (2-tailed)); however, BVI is negatively correlated with the CVP with no statistically significant difference. Through the analysis of ROC curve, Dmax, Dmin, RVI, BVmax, and BVmin could be used to predict the CVP > 6 mmHg in these patients, and the best index was BVmax; BVI diagnosis was not effective. Ultrasonic measurements of internal jugular vein diameter, respiratory variability, and blood flow velocity were correlated with preoperative CVP in elderly patients, indicating that these indexes could potentially be used to evaluate the preoperative blood volume in elderly patients.

The Spectrum of Postoperative Complications and Outcomes After Pancreaticoduodenectomy: A Retrospective Outlook From a Developing Country

Background

Pancreaticoduodenectomy is an extremely complex surgical procedure that mandates aggressive postoperative management. Unfortunately, in developing countries, the limited resources and poor postoperative care lead to multiple complications and abysmal outcomes. Therefore, our study aimed to evaluate the spectrum of postoperative complications and outcomes among patients undergoing pancreaticoduodenectomy.

Methods

This retrospective study involved a total of 97 patients who underwent pancreaticoduodenectomy for ampullary, periampullary, or pancreatic tumors. Patients with advanced metastasis and unresectable tumors were excluded from the study. Patients were studied for various parameters including the demographic details, postoperative outcomes, characteristics of the tumor, and postoperative complications.

Results

Out of 97 patients, 59 (60.8%) patients were males. The mean age of the study participants was 53.43 ± 17.89 years. Jaundice and abdominal pain were the most common presenting symptoms among the study participants. Of the 97 patients, 58 (59.8%) had malignant tumors. A total of 49 patients developed various postoperative complications including surgical site infections (10.3%), anastomosis leakage (9.27%), pancreatic fistula (9.27%), cholangitis (7.2%), and biliary leakage (4.1%). A total of 29 (29.9%) patients expired due to postoperative complications.

Conclusions

Surgical site infections, anastomosis leakage, pancreatic fistula, cholangitis, and biliary leakage are common but preventable postoperative complications after pancreaticoduodenectomy. These lead to morbidity and mortality, especially in the setting of a resource-deprived developing country. Aggressive postoperative management, improved surgical technique, better intraoperative hemostasis management, and a multi-disciplinary approach for the management of such patients can help in preventing postoperative complications and improving the postoperative outcomes.

Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta-Analysis of Analgesic Modalities

Background

This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes.

Methods

MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use.

Results

Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD.

Conclusions

EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06217-x.

Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy

BACKGROUND

Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications.

METHODS

Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications.

RESULTS

The weight change on postoperative day 1 ranged from -1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023).

CONCLUSIONS

Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.

Lack of impact of nil-per-os (NPO) time on goal-directed fluid delivery in first case versus afternoon case starts: a retrospective cohort study

BACKGROUND

Goal Directed Fluid Therapy (GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm.

METHODS

A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr., and total ml/kg/hr. between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration.

RESULTS

Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr., or ml/kg/hr., the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p = 0.64 and p = 0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured.

CONCLUSIONS

This study showed NPO periods do not influence a patient's volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.