1
|
Huisman DE, Bootsma BT, Ingwersen EW, Reudink M, Slooter GD, Stens J, Daams F. Fluid management and vasopressor use during colorectal surgery: the search for the optimal balance. Surg Endosc 2023:10.1007/s00464-023-09980-1. [PMID: 37126191 PMCID: PMC10338618 DOI: 10.1007/s00464-023-09980-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/25/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Although it is known that excessive intraoperative fluid and vasopressor agents are detrimental for anastomotic healing, optimal anesthesiology protocols for colorectal surgery are currently lacking. OBJECTIVE To scrutinize the current hemodynamic practice and vasopressor use and their relation to colorectal anastomotic leakage. DESIGN A secondary analysis of a previously published prospective observational study: the LekCheck study. STUDY SETTING Adult patients undergoing a colorectal resection with the creation of a primary anastomosis. OUTCOME MEASURES Colorectal anastomotic leakage (CAL) within 30 days postoperatively, hospital length of stay and 30-day mortality. RESULTS Of the 1548 patients, 579 (37%) received vasopressor agents during surgery. Of these, 201 were treated with solely noradrenaline, 349 were treated with phenylephrine, and 29 received ephedrine. CAL rate significantly differed between the patients receiving vasopressor agents during surgery compared to patients without (11.8% vs 6.3%, p < 0.001). CAL was significantly higher in the group receiving phenylephrine compared to noradrenaline (14.3% vs 6%, p < 0.001). Vasopressor agents were used more often in patients treated with Goal Directed Therapy (47% vs 34.6%, p < 0.001). There was a higher mortality rate in patients with vasopressors compared to the group without (2.8% vs 0.4%, p = 0.01, OR 3.8). Mortality was higher in the noradrenaline group compared to the phenylephrine and those without vasopressors (5% vs. 0.4% and 1.7%, respectively, p < 0.001). In multivariable analysis, patients with intraoperative vasopressor agents had an increased risk to develop CAL (OR 2.1, CI 1.3-3.2, p = 0.001). CONCLUSION The present study contributes to the evidence that intraoperative use of vasopressor agents is associated with a higher rate of CAL. This study helps to create awareness on the (necessity to) use of vasopressor agents in colorectal surgery patients in striving for successful anastomotic wound healing. Future research will be required to balance vasopressor agent dosage in view of colorectal anastomotic leakage.
Collapse
Affiliation(s)
- Daitlin E Huisman
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.
| | - Boukje T Bootsma
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Erik W Ingwersen
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Muriël Reudink
- Department of Surgery, Máxima Medical Center, Veldhoven/Eindhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven/Eindhoven, The Netherlands
| | - Jurre Stens
- Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Subramaniam A, Wengritzky R, Skinner S, Shekar K. Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach. Clin Colon Rectal Surg 2022; 35:244-260. [PMID: 35966378 PMCID: PMC9374534 DOI: 10.1055/s-0041-1740045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.
Collapse
Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Department of Intensive Care, The Bays Healthcare, Mornington, Victoria, Australia
| | - Robert Wengritzky
- Department of Anaesthesia, Peninsula Health, Frankston, Victoria, Australia
| | - Stewart Skinner
- Department of Surgery, Peninsula Health, Frankston, Victoria, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
3
|
Casey P, Chaudhury MP, Khan A, Amin J, Afzal A, Corallo C, Sebastian D, Atkinson M, Subar D. The impact of perioperative inotropes on the incidence of pancreatic leak following pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:392-396. [PMID: 31825007 PMCID: PMC6893053 DOI: 10.14701/ahbps.2019.23.4.392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/18/2019] [Accepted: 07/25/2019] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Pancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy. Methods Retrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula. Results One-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size. Conclusions Perioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.
Collapse
Affiliation(s)
- Patrick Casey
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | | | - Asaad Khan
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Jebran Amin
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Abdul Afzal
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Carmello Corallo
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Domnic Sebastian
- Department of Anaesthesia, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Matthew Atkinson
- Department of Anaesthesia, East Lancashire NHS Hospital Trust, Blackburn, UK
| | - Daren Subar
- Department of HPB Surgery, East Lancashire NHS Hospital Trust, Blackburn, UK
| |
Collapse
|
4
|
Laks S, Isaak RS, Strassle PD, Hance L, Kolarczyk LM, Kim HJ. Increased Intraoperative Vasopressor Use as Part of an Enhanced Recovery After Surgery Pathway for Pancreatectomy Does Not Increase Risk of Pancreatic Fistula. J Pancreat Cancer 2018; 4:33-40. [PMID: 30631856 PMCID: PMC6145536 DOI: 10.1089/pancan.2018.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose: Enhanced recovery after surgery (ERAS) pathways are increasingly implemented. Goal directed fluid therapy (GDFT) is a core component of ERAS pathways that limit excessive volume administration and is associated with increased use of intraoperative vasopressors. Vasopressor effects on anastomotic healing and pancreatic fistula are inconclusive. We hypothesized that intraoperative vasopressor use in an ERAS GDFT algorithm would not increase risk of pancreatic fistulas. Methods: We reviewed all adult patients undergoing pancreatectomy at an academic institution from January 2013 to February 2016, before and after implementation of an ERAS pathway in July 2014. Retrospective chart review was performed. Log-binomial regression, weighted by stabilized inverse probability-of-treatment weights, estimated effect of ERAS and intraoperative vasopressors on fistula risk. Results: One hundred thirty two patients met inclusion criteria: 74 (56.1%) in the ERAS cohort. No significant differences in overall leak risk (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.38-2.09) were observed between the ERAS and pre-ERAS cohorts. Similarly, vasopressor infusions, independent of ERAS pathway, did not significantly increase the risk of anastomotic leaks (RR 1.19, 95% CI 0.52-2.72). Conclusions: Increased use of vasopressor infusions as part of an ERAS pathway for pancreatic surgery is not associated with an increase in the risk of clinically significant pancreatic fistulas.
Collapse
Affiliation(s)
- Shachar Laks
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Robert S. Isaak
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Paula D. Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lyla Hance
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Lavinia M. Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Hong Jin Kim
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
5
|
van Rooijen SJ, Huisman D, Stuijvenberg M, Stens J, Roumen RMH, Daams F, Slooter GD. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36:183-200. [PMID: 27756644 DOI: 10.1016/j.ijsu.2016.09.098] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/12/2016] [Accepted: 09/26/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal anastomotic leakage (CAL) is a major surgical complication in intestinal surgery. Despite many optimizations in patient care, the incidence of CAL is stable (3-19%) [1]. Previous research mainly focused on determining patient and surgery related risk factors. Intraoperative non-surgery related risk factors for anastomotic healing also contribute to surgical outcome. This review offers an overview of potential modifiable risk factors that may play a role during the operation. METHODS Two independent literature searches were performed using EMBASE, Pubmed and Cochrane databases. Both clinical and experimental studies published in English from 1985 to August 2015 were included. The main outcome measure was the risk of anastomotic leakage and other postoperative complications during colorectal surgery. Determined risk factors of CAL were stated as strong evidence (level I and II high quality studies), and potential risk factors as either moderate evidence (experimental studies level III), or weak evidence (level IV or V studies). RESULTS The final analysis included 117 articles. Independent factors of CAL are diabetes mellitus, hyperglycemia and a high HbA1c, anemia, blood loss, blood transfusions, prolonged operating time, intraoperative events and contamination and a lack of antibiotics. Unequivocal are data on blood pressure, the use of inotropes/vasopressors, oxygen suppletion, type of analgesia and goal directed fluid therapy. No studies could be found identifying the impact of body core temperature or mean arterial pressure on CAL. Subjective factors such as the surgeons' own assessment of local perfusion and visibility of the operating field have not been the subject of relevant studies for occurrence in patients with CAL. CONCLUSION Both surgery related and non-surgery related risk factors that can be modified must be identified to improve colorectal care. Surgeons and anesthesiologists should cooperate on these items in their continuous effort to reduce the number of CAL. A registration study determining individual intraoperative risk factors of CAL is currently performed as a multicenter cohort study in the Netherlands.
Collapse
Affiliation(s)
- S J van Rooijen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands.
| | - D Huisman
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - M Stuijvenberg
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - J Stens
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - R M H Roumen
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| | - F Daams
- VU Medical Center, Department of Surgery, Amsterdam, The Netherlands
| | - G D Slooter
- Máxima Medical Center, Department of Surgery, Veldhoven, The Netherlands
| |
Collapse
|
6
|
Lolis ED, Theodoridou E, Vogiatzis N, Neonaki D, Markakis C, Daskalakis K. The safety of primary repair or anastomosis in high-risk trauma patients. Surg Today 2014; 45:730-9. [PMID: 25030128 DOI: 10.1007/s00595-014-0982-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/02/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries. METHOD In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded. RESULTS Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation. CONCLUSION Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.
Collapse
Affiliation(s)
- Evangelos D Lolis
- Surgical Department, General Hospital of Rethymno, Trantalidou 17, 74100, Rethymno, Greece,
| | | | | | | | | | | |
Collapse
|
7
|
Onur E, Akalin B, Memisoglu K, Karip AB, Aydin MT, Altun H, Ekci B. Ethyl pyruvate improves healing of colonic anastomosis in a rat model of peritonitis. Surg Innov 2012; 19:394-8. [PMID: 22298750 DOI: 10.1177/1553350611432158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND This study was designed to evaluate the effects of ethyl pyruvate (EP) on wound healing in primary colonic anastomoses in intraperitoneal sepsis. METHODS Standard left colon resection and end-to-end anastomosis were performed on 30 rats. They were grouped as control (C)--no further treatment; sepsis (S)--received 2 mL Escherichia coli (ATCC 25922) intraperitoneally (IP), and after 5 hours, standard resection and anastomosis were performed; or sepsis-group treated with EP (S-EP)--received 2 mL E coli IP, after 5 hours, standard resection and anastomosis were performed and treated with EP 50 mg/kg IP for 7 days. On the postoperative day 7, the animals were sacrificed. RESULTS The anastomosis bursting pressure in group S was significantly lower than in the other groups. There were no differences between groups C and S-EP. Tissue hydroxyproline concentrations in group C were significantly higher than in group S. CONCLUSIONS EP administration prevented intraperitoneal sepsis-induced impaired anastomotic healing of colon.
Collapse
Affiliation(s)
- Ender Onur
- Department of General Surgery, Fatih Sultan Mehmet Education and Research Hospital, Istanbul 84410, Turkey.
| | | | | | | | | | | | | |
Collapse
|