Impact of Different Crystalloid Volume Regimes on Intestinal Anastomotic Stability

Marjanović, Goran; Villain, Christian; Juettner, Eva; Hausen, Axel zur; Hoeppner, Jens; Hopt, Ulrich T.; Drognitz, Oliver; Obermaier, Robert

doi:10.1097/sla.0b013e31818b73dc

Cited by 130 publications

(80 citation statements)

References 25 publications

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“…27,28 It is postulated that increased fluid volumes can cause tissue oedema thereby reducing anastomotic strength. 29 This is particularly important in rectal cancer surgery as anastomotic leakage is associated with poor outcomes. 23,30 Our study found that anastomotic leaks were more common in the group that received more than 3500ml but this was not statistically significant.…”

Section: Discussionmentioning

confidence: 99%

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

Boland

Reynolds

McCawley

et al. 2017

annals

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INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high-and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

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Section: Discussionmentioning

confidence: 99%

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

Boland

Reynolds

McCawley

et al. 2017

annals

View full text Add to dashboard Cite

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“…2 Furthermore, a study in rats undergoing a bowel resection and anastomosis showed that excessive crystalloid results in submucosal intestinal edema, lower anastomotic bursting pressure, and a decrease in the structural stability of intestinal anastomoses in the early postoperative period. 20 Maintenance fluid requirements during surgery can be delivered with a 1-3 mLÁkg -1Áhr -1 infusion of a balanced crystalloid solution. 19,21 The aim should be to maintain preoperative body weight.…”

Section: Maintenance Fluid Therapymentioning

confidence: 99%

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

Miller

Roche

Mythen

2014

Can J Anesth/J Can Anesth

225

137

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Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a ''zero-balance'' approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and ''permissive oliguria'' could be tolerated.Résumé La gestion périopératoire optimale des liquides est un élément important des programmes de récupération rapide après la chirurgie (RRAC). La gestion des liquides dans le cadre de la RRAC doit être vue comme un continuum au travers des phases pré-, per-et postopératoires. Chaque phase est importante pour améliorer la condition du patient et des soins sous-optimaux au cours d'une de ces phases peuvent miner les meilleures pratiques déployées tout au long de la RRAC. L'objectif de la gestion préopératoire des liquides est de faire en sorte que le patient entre en salle d'opération correctement hydraté et dans un état euvolémique. Pour y parvenir, un jeûne prolongé n'est pas recommandé et le nettoyage mécanique de l'intestin est à éviter. Les patients doivent être encouragés à absorber une boisson claire riche en hydrates de carbone, deux à trois heures avant la chirurgie. Les buts de la gestion peropératoire des liquides sont de maintenir une euvolémie centrale et d'éviter un excès de sel et d'eau. Pour y parvenir, les patients subissant une intervention chirurgicale dans le cadre d'un protocole de récupération rapide devraient avoir un programme personnalisé de gestion des liquides. Dans le cadre de ce plan, l'excès de cristalloïdes doit être évité chez tous les patients. Pour des patients à faible risque subissant une intervention c...

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“…9% saline. Nevertheless, a study in rats undergoing small-bowel resection and anastomosis has shown that an excess of even a balanced crystalloid can result in submucosal intestinal oedema, a decrease in anastomotic bursting pressure and a decrease in hydroxyproline concentration in the anastomotic region, implying impairment of collagen synthesis and wound healing (48) .…”

Section: Study or Subgroupmentioning

confidence: 99%

A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right

2010

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The terminology used for describing intervention groups in randomised controlled trials (RCT) on the effect of intravenous fluid on outcome in abdominal surgery has been imprecise, and the lack of standardised definitions of the terms 'standard', 'restricted' and 'liberal' has led to some confusion and difficulty in interpreting the literature. The aims of this paper were to clarify these definitions and to use them to perform a meta-analysis of nine RCT on primarily crystalloid-based peri-operative intravenous fluid therapy in 801 patients undergoing elective open abdominal surgery. Patients who received more or less fluids than those who received a 'balanced' amount were considered to be in a state of 'fluid imbalance'. When 'restricted' fluid regimens were compared with 'standard or liberal' fluid regimens, there was no difference in post-operative complication rates (risk ratio 0 . 96 (95 % CI 0 . 56, 1 . 65), P = 0 . 89) or length of hospital stay (weighted mean difference (WMD) -1 . 77 (95% CI -4 . 36, 0 . 81) d, P = 0 . 18). However, when the fluid regimens were reclassified and patients were grouped into those who were managed in a state of fluid 'balance' or 'imbalance', the former group had significantly fewer complications (risk ratio 0 . 59 (95 % CI 0 . 44, 0 . 81), P = 0 . 0008) and a shorter length of stay (WMD -3 . 44 (95 % CI -6 . 33, -0 . 54) d, P = 0 . 02) than the latter. Using imprecise terminology, there was no apparent difference between the effects of fluid-restricted and standard or liberal fluid regimens on outcome in patients undergoing elective open abdominal surgery. However, patients managed in a state of fluid balance fared better than those managed in a state of fluid imbalance.

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Impact of Different Crystalloid Volume Regimes on Intestinal Anastomotic Stability

Cited by 130 publications

References 25 publications

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right

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