Does intraoperative fluid balance affect development of postoperative pancreatic fistula?
China: The controversy around perioperative fluid management during major abdominal surgery has been ongoing. Postoperative pancreatic fistula is a critical complication of pancreaticoduodenectomy.
Pancreaticoduodenectomy (PD) is one of the most traumatic and complex abdominal operations. It is associated with many postoperative abdominal complications, including bile leak (BL), pancreatic fistula, delayed gastric emptying (DGE), post pancreatectomy haemorrhage (PPH), and intra-abdominal infection. The incidence of postoperative pancreatic fistula ranges from 10 to 34.
Le Zhang, Union Medical College, Beijing, China, and colleagues conducted a retrospective cohort study to analyze the impact of intraoperative fluid balance on postoperative pancreatic fistula (POPF) development. The researchers in their study, published in BMC Surgery, failed to show a significant association between intraoperative fluid balance and POPF. Also, the correlations between fluid balance and other abdominal complications were statistically insignificant.
The study, however, showed a close relation between POPF with lesion site, surgery time, blood glucose, and BMI. The researchers point out the necessity to unify the definition of fluid balance and well-designed studies to confirm the optimal fluid strategy and reduce complications such as POPF.
"As of now, the intraoperative fluid management plan of pancreaticoduodenectomy (PD) should be individualized and adjusted as per the actual situation," the researchers suggested.
The authors had an opinion that whether POPF occurred depended mainly on the experience and technique of surgeons. Some previous studies have clarified various perioperative factors related to POPF. However, few studies have analyzed the correlation between intraoperative fluid management and POPF. There is no clarity on whether restrictive fluid management reduces POPF risk.
The association between intraoperative fluid balance and POPF was analyzed using Multivariate logistic regression and restricted cubic splines (RCSs). The study enrolled 567 patients who underwent open pancreaticoduodenectomy, and their laboratory, demographic, and medical data were recorded. Patients were categorized into four groups based on the quartiles of intraoperative fluid balance.
The authors reported the following findings:
· Patients' intraoperative fluid balance ranged from -8.47 to 13.56 mL/kg/h. One hundred eight patients reported postoperative pancreatic fistula, and the incidence was 19.0%.
· Using restricted cubic splines and after adjusting for potential confounders, the dose-response relationship between intraoperative fluid balance and POPF was statistically insignificant.
· The incidences of delayed gastric emptying, bile leakage, and post-pancreatectomy bleeding were 14.8%, 4.4%, and 20.8%, respectively. Intraoperative fluid balance was not linked with these abdominal complications.
· Preoperative blood glucose < 6 mmol/L, BMI ≥ 25 kg/m2, lesions not located in the pancreas, and long surgery time were independent risk factors for POPF.
The study found no remarkable association between intraoperative fluid balance and POPF. "Well-designed multicenter studies are required to explore the association between intraoperative fluid balance and POPF," the authors concluded.
Reference:
Zhang, L., Zhang, Y. & Shen, L. Effects of intraoperative fluid balance during pancreatoduodenectomy on postoperative pancreatic fistula: an observational cohort study. BMC Surg 23, 89 (2023). https://doi.org/10.1186/s12893-023-01978-9
