The Impact of Perioperative Fluid Balance on Postoperative Complications after Esophagectomy for Esophageal Cancer

Impact of perioperative fluid overload on the occurrence of postoperative pulmonary complications following lobectomy

Background

The incidence of pulmonary complications following lobectomy remains substantial, with postoperative fluid volume playing a pivotal role. However, the optimal management of fluids after lobectomy remains uncertain. This study aimed to establish a benchmark for perioperative fluid overload in patients undergoing pulmonary surgery by comparing the incidence of pulmonary complications following standard surgical procedures among patients with varying fluid volumes.

Methods

A retrospective analysis was conducted on adult patients with non-small cell lung cancer (NSCLC) who underwent lobectomy between January 2018 and January 2019. The primary exposure variable was fluid overload within the initial 24-hour period. The observation outcomes were postoperative pulmonary complications, acute kidney injury (AKI), and postoperative length of stay. Univariate and multivariate analyses were performed.

Results

Among the 300 patients included in this study, the low-volume group exhibited a significantly shorter postoperative hospital stay compared to the high-volume group (P=0.02). Furthermore, the low-volume group demonstrated a significantly lower incidence of postoperative atelectasis (P=0.03) and pulmonary infection (P=0.02) compared to the high-volume group. Moreover, logistic regression analysis revealed that the high-volume group had higher odds ratios (ORs) for developing atelectasis [OR: 2.611, 95% confidence interval (CI): 1.050-6.496, P=0.04] and pulmonary infection (OR: 2.642, 95% CI: 1.053-6.630, P=0.04) following lobectomy when compared to the low-volume group.

Conclusions

In patients with NSCLC undergoing lobectomy, reducing intravenous infusion after surgery while maintaining hemodynamic stability can effectively shorten hospitalization duration and mitigate the risk of postoperative atelectasis and pulmonary infection.

Neoadjuvant Chemotherapy Improves Feasibility of Larynx Preservation and Prognosis in Resectable Locally Advanced Cervical Esophageal Cancer

BACKGROUND

The optimal strategy for cervical advanced esophageal cancer remains controversial in terms of oncologic outcome as well as vocal and swallowing function. Recently, in East Asian countries, neoadjuvant chemotherapy (NAC) has been a standard strategy for advanced esophageal cancer.

METHODS

This study included 37 patients who underwent NAC, and 33 patients who underwent definitive chemoradiation therapy (dCRT) as larynx-preserving treatment for locally advanced cervical esophageal cancer from 2016 to 2021. This study retrospectively investigated outcomes, with comparison between NAC and dCRT for locally advanced cervical esophageal cancer.

RESULTS

Larynx preservation was successful for all the patients with NAC and dCRT. After NAC, the rate of complete or partial response was 78.4%, and 30 patients underwent larynx-preserving surgery. On the other hand, after dCRT, the complete response rate was 71.9%, and 4 patients underwent larynx-preserving salvage surgery. Overall survival (OS) and progression free survival were similar between the two groups. However, for the patients with resectable cervical esophageal cancer (cT1/2/3), the 2-year OS rate was significantly higher with NAC (79.9%) than with dCRT (56.8%) (P = 0.022), and the multivariate analyses identified only NAC and cN0, one of the two as a significantly independent factor associated with a better OS (NAC: P = 0.041; cN0, 1: P = 0.036).

CONCLUSION

The study showed that NAC as larynx-preserving surgery for resectable cervical esophageal cancer preserved function and had a better prognosis than dCRT. The authors suggest that NAC may be standard strategy for larynx preservation in patients with resectable cervical esophageal cancer.

Influence of different intraoperative fluid management on postoperative outcome after abdominal tumours resection

BACKGROUND

Intraoperative fluid management is a crucial aspect of cancer surgery, including colorectal surgery and pancreatoduodenectomy. The study tests if intraoperative multimodal monitoring reduces postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery treated by the same anaesthetic protocols with epidural analgesia.

PATIENTS AND METHODS

A prospective study was conducted in 2 parallel groups. High-risk surgical patients undergoing major abdominal surgery were randomly selected in the control group (CG), where standard monitoring was applied (44 patients), and the protocol group (PG), where cerebral oxygenation and extended hemodynamic monitoring were used with the protocol for intraoperative interventions (44 patients).

RESULTS

There were no differences in the median length of hospital stay, CG 9 days (interquartile range [IQR] 8 days), PG 9 (5.5), p = 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in the first 3 days) in CG, 0.75 mcg/L (IQR 3.19 mcg/L), than in PG, 0.3 mcg/L (0.88 mcg/L), p = 0.001. PG patients received a larger volume of intraoperative fluid; median intraoperative fluid balance +1300 ml (IQR 1063 ml) than CG; +375 ml (IQR 438 ml), p < 0.001.

CONCLUSIONS

There were significant differences in intraoperative fluid management and vasopressor use. The median postoperative value of procalcitonin was significantly higher in CG, suggesting differences in immune response to tissue trauma in different intraoperative fluid status, but there was no difference in postoperative morbidity or hospital stay.

Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer

Background

Enhanced Recovery After Surgery (ERAS) protocol for esophagectomy may reduce the high incidence of postoperative morbidity and mortality. The aim of this study was to assess the impact of properly conducted ERAS protocol with specific emphasis on fluid balance and opioid-sparing anesthesia (OSA) on postoperative major morbidity and mortality after esophagectomy.

Methods

Patients undergoing elective esophagectomy for esophageal cancer at the Hospital for Digestive Surgery, University Clinical Center of Serbia, from December 2017 to March 2021, were included in this retrospective observational study. Patients were divided into two groups: the ERAS group (OSA, intraoperative goal-directed therapy, and postoperative “near-zero” fluid balance) and the control group (opioid-based anesthesia, maintenance mean blood pressure ≥ 65 mmHg, and liberal postoperative fluid management). The primary outcome was major morbidity within 30 days from surgery and 30-day and 90-day mortality. Multivariable analysis was used to examine the effect of the ERAS protocol.

Results

A total of 121 patients were divided into the ERAS group (69 patients) and the control group (52 patients). Patients in the ERAS group was received less fentanyl, median 300 (interquartile range (IQR), 200–1,550) mcg than in control group, median 1,100 (IQR, 650–1750) mcg, p &lt; 0.001. Median intraoperative total infusion was lower in the ERAS group, 2000 (IQR, 1000–3,750) mL compared to control group, 3,500 (IQR, 2000–5,500) mL, p &lt; 0.001. However, intraoperative norepinephrine infusion was more administered in the ERAS group (52.2% vs. 7.7%, p &lt; 0.001). On postoperative day 1, median cumulative fluid balance was 2,215 (IQR, −150-5880) mL in the ERAS group vs. 4692.5 (IQR, 1770–10,060) mL in the control group, p = 0.002. After the implementation of the ERAS protocol, major morbidity was less frequent in the ERAS group than in the control group (18.8% vs. 75%, p &lt; 0.001). There was no statistical significant difference in 30-day and 90-day mortality (p = 0.07 and p = 0.119, respectively). The probability of postoperative major morbidity and interstitial pulmonary edema were higher in control group (OR 5.637; CI95%:1.178–10.98; p = 0.030 and OR 5.955; CI95% 1.702–9.084; p &lt; 0.001, respectively).

Conclusion

A major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study

BACKGROUND

Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear.

METHODS

After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications.

RESULTS

Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels.

CONCLUSIONS

Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

The impact of intraoperative and postoperative fluid balance on complications for transthoracic esophagectomy: a retrospective analysis

OBJECTIVE

Transthoracic esophagectomy is associated with significant morbidity and mortality. Therefore, it is imperative to optimize perioperative management and minimize complications. In this retrospective analysis, we evaluated the association between fluid balance and esophagectomy complications at a tertiary hospital in Melbourne, Australia, with a particular focus on respiratory morbidity and anastomotic leaks. Cumulative fluid balance was calculated intraoperatively, postoperatively in recovery postoperative day (POD) 0, and on POD 1 and 2. High and low fluid balance was defined as greater than or less than the median fluid balance, respectively, and postoperative surgical complications were graded using the Clavien-Dindo classification.

RESULTS

In total, 109 patients, with an average age of 64 years, were included in this study. High fluid balance on POD 0, POD1 and POD 2 was associated with a higher incidence of anastomotic leak (OR 8.59; 95%CI: 2.64-39.0). High fluid balance on POD 2 was associated with more severe complications (of any type) (OR 3.33; 95%CI: 1.4-8.26) and severe pulmonary complications (OR 3.04; 95%CI: 1.27-7.67). For every 1 L extra cumulative fluid balance in POD 1, the odds of a major complication increase by 15%, while controlling for body mass index (BMI) and American Society of Anaesthesiologists (ASA) class. The results show that higher cumulative fluid balance is associated with worsening postoperative outcomes in patients undergoing transthoracic esophagectomy. Restricted fluid balance, especially postoperatively, may mitigate the risk of postoperative complications - however prospective trials are required to establish this definitively.