Systematic Review and Meta-analysis of Restrictive Perioperative Fluid Management in Pancreaticoduodenectomy
Brian P. Chen
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorMarian Chen
Faculty of Medicine, University of Toronto, Toronto, ON, Canada
Search for more papers by this authorSean Bennett
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Search for more papers by this authorKristina Lemon
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorKimberly A. Bertens
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorFady K. Balaa
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorCorresponding Author
Guillaume Martel
- [email protected]
- 613-737-8899
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Tel.: 613-737-8899, [email protected]Search for more papers by this authorBrian P. Chen
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorMarian Chen
Faculty of Medicine, University of Toronto, Toronto, ON, Canada
Search for more papers by this authorSean Bennett
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Search for more papers by this authorKristina Lemon
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorKimberly A. Bertens
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorFady K. Balaa
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Search for more papers by this authorCorresponding Author
Guillaume Martel
- [email protected]
- 613-737-8899
Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital – General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, K1H 8L6 Ottawa, ON, Canada
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Tel.: 613-737-8899, [email protected]Search for more papers by this authorThis work was presented at the American College of Surgeons Clinical Congress, Washington, DC, October 18, 2016.
Abstract
Background
There is significant interest and controversy surrounding the effect of restrictive fluid management on outcomes in major gastrointestinal surgery. This has been most studied in colorectal surgery, although the literature relating to pancreaticoduodenectomy (PD) patients is growing. The aim of this paper was to generate a comprehensive review of the available evidence for restrictive perioperative fluid management strategies and outcomes in PD.
Methods
MEDLINE/PubMed, Embase, and the Cochrane Library were searched from inception to April 2017. A review protocol was utilized and registered with PROSPERO. Primary citations that evaluated perioperative fluid management in PD, including those as part of a clinical pathway, were considered. The primary outcome was postoperative pancreatic fistula (POPF). Secondary outcomes included delayed gastric emptying (DGE), complication rate, length of stay (LOS), mortality, and readmission.
Results
A total of six studies involving 846 patients were included (2009–2015), of which four were RCTs. Pooled analysis of RCTs and high-quality observational studies found no effect of restrictive intraoperative fluid management on POPF, DGE, complication rate, LOS, mortality, and readmission. Only one study assessed postoperative fluid management exclusively and found prolonged LOS in patients in the restricted fluid group.
Conclusion
Based on results of RCTs and high-quality observational studies, intraoperative fluid restriction in PD has not been shown to significantly affect postoperative outcomes. There are too few studies assessing postoperative fluid management to draw conclusions at this time.
References
- 1AhmadSA, EdwardsMJ, SuttonJM et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg (2012) 256(3): 529–53710.1097/SLA.0b013e318265ef0b22868373
- 2WinterJM, CameronJL, CampbellKA et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg (2006) 10(9): 1199–121010.1016/j.gassur.2006.08.01817114007(discussion 1210–1191)
- 3BragaM, CaprettiG, PecorelliN et al. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg (2011) 254(5): 702–70710.1097/SLA.0b013e31823598fb22042466(discussion 707–708)
- 4SchmidtCM, PowellES, YiannoutsosCT et al. Pancreaticoduodenectomy: a 20-year experience in 516 patients. Arch Surg (2004) 139(7): 718–72510.1001/archsurg.139.7.71815249403(discussion 725–717)
- 5Fernandez-del CastilloC, Morales-OyarvideV, McGrathD et al. Evolution of the Whipple procedure at the Massachusetts General Hospital. Surgery (2012) 152(3 Suppl 1): S56–S6310.1016/j.surg.2012.05.02222770961
- 6GrobmyerSR, PieracciFM, AllenPJ et al. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg (2007) 204(3): 356–36410.1016/j.jamcollsurg.2006.11.01717324768
- 7EmickDM, RiallTS, CameronJL et al. Hospital readmission after pancreaticoduodenectomy. J Gastrointest Surg (2006) 10(9): 1243–125210.1016/j.gassur.2006.08.01617114011(discussion 1252–1243)
- 8SantemaTB, VisserA, BuschOR et al. Hospital costs of complications after a pancreatoduodenectomy. HPB (Oxford) (2015) 17(8): 723–73110.1111/hpb.12440
- 9EnestvedtCK, DiggsBS, CasseraMA et al. Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg (2012) 204(3): 332–33810.1016/j.amjsurg.2011.10.01922464011
- 10WuW, HeJ, CameronJL et al. The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma. Ann Surg Oncol (2014) 21(9): 2873–288110.1245/s10434-014-3722-624770680
- 11LawsonEH, HallBL, LouieR et al. Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings. Ann Surg (2013) 258(1): 10–1810.1097/SLA.0b013e31828e3ac323579579
- 12GaniF, HundtJ, MakaryMA et al. Financial impact of postoperative complication following hepato-pancreatico-biliary surgery for cancer. Ann Surg Oncol (2016) 23(4): 1064–107010.1245/s10434-015-5042-x26714947
- 13HartRA, DupaixJP, RusaR et al. Reduction of airway complications with fluid management protocol in patients undergoing cervical decompression and fusion across the cervicothoracic junction. Spine (Phila Pa 1976) (2013) 38(18): E1135–E114010.1097/BRS.0b013e31829914ed
- 14NossamanVE, RichardsonWS3rd, WooldridgeJBJr et al. Role of intraoperative fluids on hospital length of stay in laparoscopic bariatric surgery: a retrospective study in 224 consecutive patients. Surg Endosc (2015) 29(10): 2960–296910.1007/s00464-014-4029-125515983
- 15EttingerKS, YildirimY, Van EssJM et al. Impact of intraoperative fluid administration on length of postoperative hospital stay following orthognathic surgery. J Oral Maxillofac Surg (2015) 73(1): 22–2910.1016/j.joms.2014.07.02925443382
- 16McArdleGT, McAuleyDF, McKinleyA et al. Preliminary results of a prospective randomized trial of restrictive versus standard fluid regime in elective open abdominal aortic aneurysm repair. Ann Surg (2009) 250(1): 28–3410.1097/SLA.0b013e3181ad61c819561485
- 17MythenMG, WebbAR Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med (1994) 20(2): 99–10410.1007/BF017076628201106
- 18MarjanovicG, VillainC, JuettnerE et al. Impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg (2009) 249(2): 181–18510.1097/SLA.0b013e31818b73dc19212167
- 19KulemannB, TimmeS, SeifertG et al. Intraoperative crystalloid overload leads to substantial inflammatory infiltration of intestinal anastomosesߝa histomorphological analysis. Surgery (2013) 154(3): 596–60310.1016/j.surg.2013.04.01023876362
- 20HolteK, SharrockNE, KehletH Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth (2002) 89(4): 622–63210.1093/bja/aef22012393365
- 21NessimC, SiderisL, TurcotteS et al. The effect of fluid overload in the presence of an epidural on the strength of colonic anastomoses. J Surg Res (2013) 183(2): 567–57310.1016/j.jss.2013.03.03023578750
- 22SrinivasaS, HillAG Perioperative fluid administration: historical highlights and implications for practice. Ann Surg (2012) 256(6): 1113–111810.1097/SLA.0b013e31825a2f2222824855
- 23LoboDN, BostockKA, NealKR et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet (2002) 359(9320): 1812–181810.1016/S0140-6736(02)08711-112044376
- 24BrandstrupB, TonnesenH, Beier-HolgersenR et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg (2003) 238(5): 641–64810.1097/01.sla.0000094387.50865.2314578723
- 25NisanevichV, FelsensteinI, AlmogyG et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology (2005) 103(1): 25–3210.1097/00000542-200507000-0000815983453
- 26KabonB, AkcaO, TaguchiA et al. Supplemental intravenous crystalloid administration does not reduce the risk of surgical wound infection. Anesth Analg (2005) 101(5): 1546–155310.1213/01.ANE.0000180217.57952.FE16244030
- 27KalyanJP, RosbergenM, PalN et al. Randomized clinical trial of fluid and salt restriction compared with a controlled liberal regimen in elective gastrointestinal surgery. Br J Surg (2013) 100(13): 1739–174610.1002/bjs.930124227358
- 28MacKayG, FearonK, McConnachieA et al. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg (2006) 93(12): 1469–147410.1002/bjs.559317078116
- 29Abraham-NordlingM, HjernF, PollackJ et al. Randomized clinical trial of fluid restriction in colorectal surgery. Br J Surg (2012) 99(2): 186–19110.1002/bjs.770221948211
- 30FutierE, ConstantinJM, PetitA et al. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg (2010) 145(12): 1193–120010.1001/archsurg.2010.27521173294
- 31RahbariNN, ZimmermannJB, SchmidtT et al. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg (2009) 96(4): 331–34110.1002/bjs.655219283742
- 32BolandMR, NooraniA, VartyK et al. Perioperative fluid restriction in major abdominal surgery: systematic review and meta-analysis of randomized, clinical trials. World J Surg (2013) 37(6): 1193–120210.1007/s00268-013-1987-823463399
- 33VaradhanKK, LoboDN A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc (2010) 69(4): 488–49810.1017/S002966511000173420515521
- 34ChongPC, GrecoEF, StothartD et al. Substantial variation of both opinions and practice regarding perioperative fluid resuscitation. Can J Surg (2009) 52(3): 207–21419503665
- 35MoherD, LiberatiA, TetzlaffJ et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med (2009) 6(7): e100009710.1371/journal.pmed.100009719621072
- 36StroupDF, BerlinJA, MortonSC et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA (2000) 283(15): 2008–201210.1001/jama.283.15.200810789670
- 37HigginsJP, AltmanDG, GotzschePC et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ (2011) 343: d592810.1136/bmj.d592822008217
- 38SlimK, NiniE, ForestierD et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg (2003) 73(9): 712–71610.1046/j.1445-2197.2003.02748.x12956787
- 39AbrahamNS, ByrneCJ, YoungJM et al. Meta-analysis of well-designed nonrandomized comparative studies of surgical procedures is as good as randomized controlled trials. J Clin Epidemiol (2010) 63(3): 238–24510.1016/j.jclinepi.2009.04.00519716267
- 40HozoSP, DjulbegovicB, HozoI Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol (2005) 5: 1310.1186/1471-2288-5-1315840177
- 41HigginsJP, ThompsonSG, DeeksJJ et al. Measuring inconsistency in meta-analyses. BMJ (2003) 327(7414): 557–56010.1136/bmj.327.7414.55712958120
- 42FischerM, MatsuoK, GonenM et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg (2010) 252(6): 952–95810.1097/SLA.0b013e3181ff36b121107104
- 43LavuH, SellNM, CarterTI et al. The HYSLAR trial: a prospective randomized controlled trial of the use of a restrictive fluid regimen with 3% hypertonic saline versus lactated ringers in patients undergoing pancreaticoduodenectomy. Ann Surg (2014) 260: 445–45510.1097/SLA.000000000000087225115420
- 44van SamkarG, EshuisWJ, BenninkRJ et al. Intraoperative fluid restriction in pancreatic surgery: a double blinded randomised controlled trial. PLoS ONE (2015) 10(10): e014029410.1371/journal.pone.014029426465290
- 45VermeulenH, HoflandJ, LegemateDA et al. Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial. Trials (2009) 10: 5010.1186/1745-6215-10-5019583868
- 46BragaM, PecorelliN, AriottiR et al. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg (2014) 38(11): 2960–296610.1007/s00268-014-2653-524870390
- 47WangS, WangX, DaiH et al. The effect of intraoperative fluid volume administration on pancreatic fistulas after pancreaticoduodenectomy. J Investig Surg (2014) 27(2): 88–9410.3109/08941939.2013.839766
- 48BassiC, DervenisC, ButturiniG et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery (2005) 138(1): 8–1310.1016/j.surg.2005.05.00116003309
- 49WenteMN, BassiC, DervenisC et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery (2007) 142(5): 761–76810.1016/j.surg.2007.05.00517981197
- 50DindoD, DemartinesN, ClavienPA Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg (2004) 240(2): 205–21310.1097/01.sla.0000133083.54934.ae15273542
- 51BrandstrupB Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol (2006) 20(2): 265–28310.1016/j.bpa.2005.10.00716850777
- 52MythenMG, SwartM, AchesonN et al. Perioperative fluid management: consensus statement from the enhanced recovery partnership. Perioper Med (Lond) (2012) 1: 210.1186/2047-0525-1-2
- 53NavarroLH, BloomstoneJA, AulerJOJr et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) (2015) 4: 310.1186/s13741-015-0014-z
- 54WilmsH, MittalA, HaydockMD et al. A systematic review of goal directed fluid therapy: rating of evidence for goals and monitoring methods. J Crit Care (2014) 29(2): 204–20910.1016/j.jcrc.2013.10.01924360819
- 55RollinsKE, LoboDN Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg (2016) 263(3): 465–47610.1097/SLA.000000000000136626445470
- 56LassenK, CoolsenMM, SlimK et al. Guidelines for perioperative care for pancreaticoduodenectomy: enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr (2012) 31(6): 817–83010.1016/j.clnu.2012.08.01123079762
