Perioperative fluids and complications after pancreatoduodenectomy within an enhanced recovery pathway

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.

Download Full-text

Correlating complications of transurethral complications of prostate using the Charlson’s Comorbidity Index

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v18i3.15317 ◽

2016 ◽

Vol 18 (3) ◽

pp. 55

Author(s):

Aditya Kumar ◽

Bhoj Raj Luitel ◽

Uttam Kumar Sharma

Keyword(s):

Postoperative Complications ◽

Classification System ◽

Analytical Study ◽

University Teaching ◽

P Value ◽

Transurethral Resection Of Prostate ◽

Clavien Classification ◽

Comorbidity Index ◽

Clavien Classification System ◽

One Year

Introduction: Ageing is a continuous, universal and progressive process associated with an increasing incidence of comorbidities. Benign Enlargement of Prostate (BEP) is major cause of morbidity in the ageing men. Transurethral Resection of Prostate (TURP) is the Gold Standard for patients with BEP and delivers durable outcomes, however, is associated with morbidity and mortality.This study was conducted to analyze the correlation of these comorbidities in ageing men with the incidence of complications of TURP.Objective: To report and grade operative complications of TURP using Modified Clavien Classification System (MCCS) and analyze whether Charlson Comorbidity Index (CCI) predicts complications after TURP.Methods: This is a prospective analytical study of 77 patients diagnosed as Benign Prostatic Hyperplasia (BPH) undergoing TURP over one year at Tribhuvan University Teaching Hospital. Preoperative morbidity was classified using Charlsons Comorbidity and postoperative complications were graded according to Modified Clavien Classification System (MCCS) into five grades (Grades I, II, IIIa, IIIb, IVa, IVb and V) according to severity followed till 90 days after TURP.Results: Fourteen out of seventy seven (18.2%) patients developed postoperative complications. CCI Scores of <1 were observed in 73 (94.8%) and >2 in 4 (5.2%) patients, constituting the bulk of 93%, Grade IV complications were 7% and no mortality was observed. Patients with higher CCI scores showed statistically significant increase in the grade of postoperative complication and positively correlated to MCCS (ρ of .295; p value <0.009).Conclusion: Men with higher CCI scores have significantly higher grade of postoperative complications.

Download Full-text

Reduced postoperative complications and length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol

10.26226/morressier.58f5b030d462b80296c9e486 ◽

2017 ◽

Author(s):

Javier Ripollés-Melchor

Keyword(s):

Postoperative Complications ◽

Colorectal Surgery ◽

Hospital Stay ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Enhanced Recovery Protocol

Download Full-text

Perioperative liberal versus restrictive fluid strategies and postoperative outcomes: a systematic review and metanalysis on randomised-controlled trials in major abdominal elective surgery

Critical Care ◽

10.1186/s13054-021-03629-y ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Antonio Messina ◽

Chiara Robba ◽

Lorenzo Calabrò ◽

Daniel Zambelli ◽

Francesca Iannuzzi ◽

...

Keyword(s):

Systematic Review ◽

Postoperative Complications ◽

Randomised Controlled Trials ◽

Elective Surgery ◽

Fluid Management ◽

Risk Difference ◽

Controlled Trials ◽

Perioperative Fluid Management ◽

Liberal Approach ◽

Randomised Controlled

Abstract Background Postoperative complications impact on early and long-term patients’ outcome. Appropriate perioperative fluid management is pivotal in this context; however, the most effective perioperative fluid management is still unclear. The enhanced recovery after surgery pathways recommend a perioperative zero-balance, whereas recent findings suggest a more liberal approach could be beneficial. We conducted this trial to address the impact of restrictive vs. liberal fluid approaches on overall postoperative complications and mortality. Methods Systematic review and meta-analysis, including randomised controlled trials (RCTs). We performed a systematic literature search using MEDLINE (via Ovid), EMBASE (via Ovid) and the Cochrane Controlled Clinical trials register databases, published from 1 January 2000 to 31 December 2019. We included RCTs enrolling adult patients undergoing elective abdominal surgery and comparing the use of restrictive/liberal approaches enrolling at least 15 patients in each subgroup. Studies involving cardiac, non-elective surgery, paediatric or obstetric surgeries were excluded. Results After full-text examination, the metanalysis finally included 18 studies and 5567 patients randomised to restrictive (2786 patients; 50.0%) or liberal approaches (2780 patients; 50.0%). We found no difference in the occurrence of severe postoperative complications between restrictive and liberal subgroups [risk difference (95% CI) = 0.009 (− 0.02; 0.04); p value = 0.62; I2 (95% CI) = 38.6% (0–66.9%)]. This result was confirmed also in the subgroup of five studies having a low overall risk of bias. The liberal approach was associated with lower overall renal major events, as compared to the restrictive [risk difference (95% CI) = 0.06 (0.02–0.09); p value = 0.001]. We found no difference in either early (p value = 0.33) or late (p value = 0.22) postoperative mortality between restrictive and liberal subgroups Conclusions In major abdominal elective surgery perioperative, the choice between liberal or restrictive approach did not affect overall major postoperative complications or mortality. In a subgroup analysis, a liberal as compared to a restrictive perioperative fluid policy was associated with lower overall complication renal major events, as compared to the restrictive. Trial Registration CRD42020218059; Registration: February 2020, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=218059.

Download Full-text

Activity Tracking After Surgery: Does It Correlate With Postoperative Complications?

The American Surgeon ◽

10.1177/0003134820988818 ◽

2021 ◽

pp. 000313482098881

Author(s):

Yehonatan Nevo ◽

Tali Shaltiel ◽

Naama Constantini ◽

Danny Rosin ◽

Mordechai Gutman ◽

...

Keyword(s):

Postoperative Complications ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

Inverse Correlation ◽

Complication Rates ◽

Activity Tracking ◽

Primary Endpoints ◽

Specific Complication ◽

Secondary Endpoints ◽

Enhanced Recovery Programs

Background Postoperative ambulation is an important tenet in enhanced recovery programs. We quantitatively assessed the correlation of decreased postoperative ambulation with postoperative complications and delays in gastrointestinal function. Methods Patients undergoing major abdominal surgery were fitted with digital ankle pedometers yielding continuous measurements of their ambulation. Primary endpoints were the overall and system-specific complication rates, with secondary endpoints being the time to first passage of flatus and stool, the length of hospital stay, and the rate of readmission. Results 100 patients were enrolled. We found a significant, independent inverse correlation between the number of steps on the first and second postoperative days (POD1/2) and the incidence of complications as well as the recovery of GI function and the likelihood of readmission ( P < .05). POD2 step count was an independent risk factor for severe complications ( P = .026). Discussion Digitally quantified ambulation data may be a prognostic biomarker for the likelihood of severe postoperative complications.

Download Full-text

Reconstruction of upper mediastinal pleura reduces postoperative complications in enhanced recovery surgery system after esophagectomy: A propensity score matching study

Journal of Surgical Oncology ◽

10.1002/jso.26686 ◽

2021 ◽

Author(s):

Lei Xu ◽

Xian‐kai Chen ◽

Hou‐nai Xie ◽

Ya‐Fan Yang ◽

Rui‐xiang Zhang ◽

...

Keyword(s):

Postoperative Complications ◽

Propensity Score ◽

Propensity Score Matching ◽

Enhanced Recovery ◽

Mediastinal Pleura

Download Full-text

238 SERUM ALBUMIN EARLY DECREASE IS AN INDEPENDENT PREDICTOR OF MAJOR COMPLICATIONS AFTER ONCOLOGICAL ESOPHAGECTOMY; RESULTS FROM A LARGE EUROPEAN SERIES

Diseases of the Esophagus ◽

10.1093/dote/doab052.238 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Ismail Labgaa ◽

Styliani Mantziari ◽

Michael Winiker-Seeberger ◽

Jerôme Pasquier ◽

Marguerite Messier ◽

...

Keyword(s):

Predictive Value ◽

Independent Predictor ◽

Multivariable Analysis ◽

Length Of Hospital Stay ◽

Adverse Outcomes ◽

Major Surgery ◽

Roc Curve Analysis ◽

Comprehensive Complication Index ◽

Major Complications ◽

Patients At Risk

Abstract The predictive value of postoperative albuminemia decrease (ΔAlb) has been increasingly evidenced in different types of major surgery but data on esophagectomy remain scarce. This study aimed to assess the predictive value of ΔAlb for adverse short-term outcomes after oncological esophagectomy. Methods Retrospective analysis of an international multicentric cohort of patients undergoing oncological esophagectomy between 2006–2017. Patients with missing pre- and postoperative albumin values were excluded from the analysis. Primary endpoint was postoperative morbidity according to Clavien classification. Secondary endpoints were Comprehensive Complication Index (CCI) and length of hospital stay (LoS). Results A total of 1046 patients were analyzed. Major complications were reported in 363 (34.7%) patients. Albuminemia showed a rapid postoperative decrease on postoperative day 1 (POD1) (ΔAlb POD1) with a median value of 11 g/L. ROC curve analysis determined a cut-off of 11 g/L for the prediction of overall complications. Patients with ΔAlb POD1 ≥ 11 g/L showed increased overall complications (p = 0.004), major complications (p = 0.009) and CCI (p = 0.006) while LoS was comparable (p = 0.099). On multivariable analysis, ΔAlb POD1 ≥ 11 g/L was an independent predictor of overall (OR: 1.55; 95% CI 1.09–2.21; p = 0.015) and major complications (OR: 1.43; 95% CI 1.09–1.89; p = 0.009). Conclusion Oncological esophagectomy induced a rapid decrease of albuminemia. ΔAlb POD1 ≥ 11 g/L was independently associated with the occurrence of overall and major postoperative complications. ΔAlb appears as a promising biomarker to detect patients at risk of adverse outcomes after oncological esophagectomy.

Download Full-text

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1740125 ◽

2021 ◽

Author(s):

Nicholas T. Haddock ◽

Ricardo Garza ◽

Carolyn E. Boyle ◽

Sumeet S. Teotia

Keyword(s):

Breast Reconstruction ◽

Patient Outcomes ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Compliance Rate ◽

Fluid Management ◽

Control Group ◽

Diep Flap ◽

Deep Inferior Epigastric Perforator ◽

Eras Protocol

Abstract Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Download Full-text

SP6.1.11 The Effect of the Enhanced Recovery Programme for Liver Surgery on Long Term Survival

British Journal of Surgery ◽

10.1093/bjs/znab361.138 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Kalaiyarasi Arujunan ◽

Abdulwarith Shugaba ◽

Harmony Uwadiae ◽

Joel Lambert ◽

Georgios Sgourakis ◽

...

Keyword(s):

Overall Survival ◽

Multivariate Analysis ◽

Postoperative Complications ◽

Liver Surgery ◽

Patient Survival ◽

Enhanced Recovery ◽

Readmission Rates ◽

Term Survival ◽

Significant Difference

Abstract Aims The Enhanced Recovery Programme for Liver Surgery (ERPLS) has been shown to promote functional recovery and reduce hospital stay. However, its effect on long term survival has yet to be established. The aim of this study was to determine the effect of the ERPLS on 5-year patient survival. Methods This was a retrospective study of patients who underwent liver resection for colorectal liver metastasis (CRLM) between January 2011 and December 2016 at a regional hepatobiliary centre. The cohort comprised of 60 pre-ERPLS and 60 post-ERPLS patients. The primary outcome was 5-year patient survival. The secondary outcomes were length of stay (LOS), postoperative complications and 90-day readmission rates. Multivariate analysis was performed to identify independent predictors of overall survival. Results There was no significant difference in the age (p = 0.960), gender (p = 0.332) and type of resection (p = 0.198) between both groups. ERPLS was not an independent predictor for overall survival (Gehan Wilcoxon Test, p = 0.828). There was no significant difference in the LOS (p = 0.874) and 90-day readmission rates (p = 0.349). Major postoperative complications (>3a Clavien-Dindo classification) were significantly less in the ERPLS group (p = 0.02). On multivariate analysis, positive resection margins and major postoperative complications were independent predictors for overall survival. Conclusions ERPLS does not seem to have an effect on long term patient survival. However, it appears to reduce the rate of major postoperative complications. LOS and 90-day readmission rates were not influenced by ERPLS.

Download Full-text