A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an Enhanced Recovery After Surgery program SUMMARY There is continued controversy regarding the benefits of goal-directed fluid therapy, with earlier studies showing marked improvement in morbidity and length-of-stay that have not been replicated more recently. The aim of this study was to compare patient outcomes in elective colorectal surgery patients having goaldirected versus restrictive fluid therapy. Inclusion criteria included suitability for an Enhanced Recovery After Surgery care pathway and patients with an American Society of Anesthesiologists Physical Status score of 1 to 3. Patients were intraoperatively randomised to either restrictive or Doppler-guided goal-directed fluid therapy. The primary outcome was length-of-stay; secondary outcomes included complication rate, change in haemodynamic variables and fluid volumes. One hundred patients, 50 in each group, were included in the analysis. Compared to restrictive therapy, goal-directed therapy resulted in a greater volume of intraoperative fluid, 2115 (interquartile range 1350 to 2560) ml versus 1500 (1200 to 2000) ml, P=0.008, and was associated with an increase in Doppler-derived stroke volume index from beginning to end of surgery, 43.7 (16.3) to 54.2 (21.1) ml/m 2 , P <0.001, in the latter group. Length-ofstay was similar, , P=0.421. The number of patients with any complication (minor or major) was similar; 60% (30) versus 52% (26), P=0.42, or major complications, 1 (2%) versus 4 (8%), P=0.36, respectively. The increased perioperative fluid volumes and increased stroke volumes at the end of surgery in patients receiving goal-directed therapy did not translate to a significant difference in length-of-stay and we did not observe a difference in the number of patients experiencing minor or major complications.

Background Skeletal muscle depletion and subsequent functional loss is common in gastrointestinal malignancy. Usual markers of nutritional status may not be part of routine workup. The predictive value of sarcopenia was assessed and compared with clinically utilized factors. The aim of this was to assess the association between computed tomography assessed sarcopenia with outcomes in colorectal cancer resection. Methods A total of 228 consecutive patients who underwent curative colorectal cancer resection were included. Skeletal muscle area was measured at L3, with pre‐defined gender‐specific cut‐offs applied to a height standardized index. Albumin, body mass index and Subjective Global Assessment scores were recorded alongside measures of comorbidity. Predictors of complications, mortality, and recurrence were identified through multivariate logistic regression. Results Computed tomography assessed sarcopenia was significantly associated with longer stays, complications, 30‐day mortality, readmissions and recurrence at 1 year. Specific associations with major, respiratory and cardiac complications were seen. It independently predicted overall complications (odds ratio 2.96, confidence interval 1.19–7.35 P = 0.019), recurrence at 1 year (odds ratio 8.00, confidence interval 1.45–44.21, P = 0.017) and an increase in comprehensive complication index of 14 (P = 0.002). Subgroup analysis found sarcopenia predicted overall complications in rectal surgery and major complications in colonic surgery. American Society of Anesthesiologists predicted complications but not major complications while cancer stage also predicted recurrence rates. Conclusions Sarcopenia presents an objective, available predictive factor that may be superior to current biochemical and clinical measures of nutritional and functional status. This study found it to be predictive of complication rates and recurrence after curative in colorectal cancer resection.