Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery

Abstract

Background Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery. Methods This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression. Results Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52). Conclusion Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

Fluid management for critical patients undergoing urgent colectomy

“…In conclusion, the suggested thresholds are very similar to the previously described thresholds by our group in the elective setting . Our results suggest that unplanned, urgent resections not needing ICU care can be managed similarly to elective cases with regard to fluid management, as it was shown for the protocol in general .…”

“…The present study aimed to evaluate whether fluid‐management related thresholds could help in guidance during urgent colectomy performed within an ERAS protocol, in line with previous reports of our group for elective procedures . Interestingly, two very similar thresholds for overall complications in 224 patients undergoing urgent colonic resections were identified: intraoperative fluid administration of more than 3 L and weight gain at POD 2 of more than 2.3 kg.…”

“…No elective resections were considered for the present analysis. No patient overlap exists therefore with the published cohorts of elective laparoscopic and open resections . Details regarding data management within our institutional ERAS pathway and contents of the database have been previously described .…”

“…Optimal fluid management during colorectal surgery is a matter ofongoing debate . To provide a guiding tool for clinical practice, our group recently identified thresholds for elective laparoscopic and open colorectal resections: administration of >3 L of IV fluids at the day of surgery and exceeding 2.5 kg weight gain at postoperative day (POD) 2 for laparoscopic, respectively, 3.5 kg for open resections was associated with postoperative adverse events.…”

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease—A Retrospective Analysis of 76 Cases in a Tertiary Center

“…This is a little higher than as described by Nguyen et al [ 15 ]. However, in the studies from Hübner et al and Jurt et al analyzing patients undergoing colon surgery without liver cirrhosis, the respiratory failure rate was six times lower [ 29 , 30 ]. In a multivariate analysis, we found “additional surgery”, “low platelets”, and “abnormal leucocytes before surgery” as risk factors for developing pneumonia and “ASA score” for developing pleural effusion and the need for reintubation in the postoperative course.…”