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Post-operative outcomes of intra-operative restrictive and conventional fluid management in laparoscopic colorectal cancer surgery
Elif Erdogan-Ongel1, Nilufer Coskun1, Ayse Hilal Meric1, Beslen Goksoy2, Nurten Bakan1
1 Department of Anaesthesiology and Reanimation, Sancaktepe Martyr Prof. Dr. Ilhan Varank Education and Research Hospital, Istanbul, Turkey
2 Department of General Surgery, Sancaktepe Martyr Prof. Dr. Ilhan Varank Education and Research Hospital, Istanbul, Turkey
|Date of Submission||11-Jan-2022|
|Date of Decision||16-Mar-2022|
|Date of Acceptance||23-Mar-2022|
|Date of Web Publication||06-Jul-2022|
Department of Anaesthesiology and Reanimation, Sancaktepe Martyr Prof. Dr. Ilhan Varank Education and Research Hospital, Istanbul
Source of Support: None, Conflict of Interest: None
Context: Intra-operative fluid management has been shown to significantly alter a patient's clinical condition in peri-operative care. Studies in the literature that investigated the effects of different amounts of intra-operative fluids on outcomes reported conflicting results.
Aims: To compare the post-operative results of intra-operative restrictive and conventional fluid administrations in laparoscopic colorectal cancer surgery.
Settings and Design: All patients with ASA I, II and III, and those who had undergone laparoscopic colorectal cancer surgery were included. It was a retrospective, cohort study.
Subjects and Methods: A review of laparoscopic colorectal cancer surgeries performed by the same fellow-trained colorectal surgeon with different anaesthesiologists between 1 January, 2018 and 30 November, 2021.
Results: In total 80 patients were analysed; 2 patients were excluded, 28 patients were in restrictive (Group R) and 50 patients were in the conventional (Group C) group. The median age of all patients was 63 years and 74% were male. The median (interquartile ranges 25 to 75) intra-operative fluid administration was significantly different between groups; 3 ml/kg/h in Group R, and 7.2 ml/kg/h in Group C. (P < 0.001) Patients in Group C had significantly high post-operative intensive care unit admission (P < 0.05), and hospital length of stay (P = 0.005) compared to Group R.
Conclusions: Intra-operative fluid management was significantly associated with post-operative hospital length of stay and intensive care unit admission. Excessive intra-operative fluid management should be avoided in daily practice to improve the outcomes of laparoscopic colorectal cancer surgery.
Keywords: Colorectal surgery, critical care, fluid therapy, length of stay, perioperative care
|How to cite this URL:|
Erdogan-Ongel E, Coskun N, Meric AH, Goksoy B, Bakan N. Post-operative outcomes of intra-operative restrictive and conventional fluid management in laparoscopic colorectal cancer surgery. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=350043
| ¤ Introduction|| |
Every year approximately 300 million patients undergo major surgery, and intra-operative care in surgery is continuously improving. Intra-operative interventions have been shown to significantly alter a patient's clinical condition in peri-operative care. Fluid management is one of the most important issues to consider during intra-operative interventions. In enhanced recovery after surgery (ERAS) protocols, restrictive intra-operative fluid management is a key component with fluid intake up to 2 h before surgery and avoidance of mechanical bowel preparation.,, However, protocoled goal-directed fluid management or ERAS is not routinely followed in daily practice. Therefore, abdominal surgical procedures are associated with dehydration due to the underlying illness, bowel preparation and pre-operative fasting. In the literature, it has been shown that both fluid excess and hypovolaemia might affect the patient's healing.,,, Hypoproteinaemia and tissue oedema caused by fluid excess of crystalloids may cause post-operative ileus, delay gastric emptying and decrease intestinal transit time. However, besides that, hypovolaemia can lead to organ hypoperfusion and can increase injury.
There are three major indications for fluid administration: resuscitation, replacement and maintenance. Elective surgeries include replacement fluid, which is prescribed to correct fluid deficit that cannot be compensated by oral intake, and maintenance fluid, which is prescribed to cover the need in patients who are unable to ingest food or fluids.,,
The biggest challenge is maintaining patients in the optimal fluid range in an intra-operative setting. Studies in the literature that investigated the effects of different amounts of intra-operative fluids on the outcome, reported conflicting results. The optimal intra-operative fluid regimen remains unclear.
In our study, we aimed to compare the post-operative outcomes of intra-operative restrictive and conventional fluid administration in laparoscopic colorectal cancer surgeries.
| ¤ Subjects and Methods|| |
In this retrospective study, we analysed 80 patients, who underwent laparoscopic colorectal cancer surgery between 1 January 2018 and 30 November 2021, by the same fellowship-trained colorectal surgeon (BG) with different anaesthesiologists. Ethical approval for this study (Ethical Committee N: 2021/241) was provided by the Ethical Committee of Education and Research Hospital on 8 December 2021. All patients with ASA I, II and III, and those who had undergone laparoscopic colorectal cancer surgery were included in our study. Patients who were ASA IV, non-laparoscopic colorectal surgeries, non-cancer surgeries, emergency surgeries or laparoscopic surgeries which were converted to open surgeries were excluded. All patients underwent mechanical bowel preparation before the surgery, according to the surgery department's protocol. Electrocardiography, invasive blood pressure with radial cannulation and oxygen saturation were measured in every patient. Anaesthesiology department laparoscopic colorectal cancer surgery protocol included premedication with intravenous (IV) midazolam (0.03 mg/kg), general anaesthesia with IV propofol (2 mg/kg), fentanyl (2 μg/kg) and rocuronium (0.6 mg/kg), and maintained with sevoflurane in a mixture of 50% oxygen and 50% air with 2 l. dk−1 flow rate. Intraoperatively, analgesia was provided with remifentanil infusion (0.05 to 0.25 μg/kg/min) titrated to maintain heart rate and blood pressure within ±20% of the baseline values. Lungs were ventilated with a tidal volume of 6–8 ml/kg and with a positive end-expiratory pressure of 5 cm H2O. End-tidal carbon dioxide was maintained at between 35 and 40 mmHg by adjusting the respiratory rate. Patients with ASA III status were admitted to the intensive care unit (ICU). Although, ASA I and II patients with intra-operative haemodynamic or metabolic instability in this major surgery were admitted to the ICU. Patients, who did not need ICU admission but required close follow-up due to intra-operative events in the early post-operative period, were admitted to the post-anaesthesia care unit (PACU) according to the anaesthesiologist's preference.
Patient sex, age, weight, ASA score, smoking history, co-morbidities (diabetes mellitus [DM], hypertension [HT], congestive heart disease [CHD], lung disease, cerebrovascular disease, liver failure and renal failure) and pre-operative haematocrit, lymphocyte, c-reactive protein (CRP), albumin, creatinine and estimated glomerular filtration rate (eGFR) values were recorded. Intra-operative data included the presence of hypotension (systolic arterial pressure <90 mmHg), tachycardia (heart rate >120 min−1), total amount of fluid administrated, type and amount of fluid administered (crystalloid or colloid), blood transfusion, use of inotropes, diuresis and duration of surgery.
In the calculation of intra-operative fluid, pre-operative replacement fluid due to fasting was subtracted from the total given fluid, and the ml/kg/h value was determined according to the remaining maintenance fluid amount, patient's weight and duration of surgery. According to textbook recommendations, the conventional fluid management is 4–8 ml/kg/h in resection surgeries. Restrictive fluid management was defined as ≤4 ml/kg/h. In compliance with the fluid administration, the patients were divided into those who received conventional fluid resuscitation (>4 ml/kg/h) (Group C) and those who received restrictive fluid resuscitation (≤4 ml/kg/h) (Group R). From the post-operative data, complications, intensive care unit (ICU) length of stay (LOS), hospital LOS, post-operative haematocrit, lymphocyte, CRP, albumin, creatinine, eGFR values and in-hospital mortality were recorded. The post-operative data from the two groups were compared.
The mean, standard deviation, median, minimum, maximum value frequency and percentage were used for descriptive statistics. The distribution of variables was checked with Kolmogorov–Smirnov test. The independent samples t-test and Mann–Whitney U test was used for the comparison of quantitative data. The Wilcoxon test was used for the repeated measurements. The Chi-square test was used to compare the comparison of qualitative data. SPSS 28.0 (IBM Corp., Armonk, NY, USA) was used for statistical analyses.
| ¤ Results|| |
Eighty patients, who underwent laparoscopic colorectal cancer surgery between 1 January, 2018 and 30 November, 2021, by the same surgeon, were analysed. Two patients were excluded due to the conversion to open surgeries. Seventy-eight patients were enrolled to the study [Figure 1]. According to our calculation, 28 patients had intra-operative restrictive fluid management (≤4 ml/kg/h, Group R) and 50 patients had intra-operative conventional fluid management (>4 ml/kg/h, Group C). There were no significant differences in the demographic variables between the two groups, except weight. Group R had significantly higher body weights than Group C (84 vs. 73 kg). Five patients in Group R and 12 patients in Group C were ASA III (uncontrolled DM n = 3, uncontrolled HT n = 2, advanced COPD n = 2, CHD n = 8, renal failure n = 2) [Table 1].
There were no significant intergroup differences in surgery type (colon or rectum surgery), operative time, intra-operative hypotension (systolic arterial pressure <90 mmHg), intra-operative inotrope drug use, intra-operative blood transfusion and ICU LOS. Intra-operative ml/kg/h fluid administration was significantly different between groups (P < 0.001). There was no significant difference in intra-operative inotrop use and blood transfusion. One patient in Group C underwent intra-operative inotrop agent use. One patient in Group R and two patients in Group C underwent intra-operative blood transfusion. Diuresis was significantly higher in Group C (P < 0.05). One patient (3%) in Group R and 7 (14%) patients in Group C were transferred to PACU (P < 0.001). Five patients (17%) in Group R and 16 patients (32%) in Group C had post-operative ICU admission (P < 0.05). Mean hospital LOS was 7.4 ± 4.4 days in all patients There was a significant difference in hospital LOS between groups; 6.4 ± 3.8 days in Group R, and 7.9 ± 4.6 days in Group C (P = 0.005) Two patients in Group R and four patients in Group C experienced post-operative complication with no significant difference. No hospital mortality was observed in any patient [Table 2].
There was a significant difference in pre-operative and post-operative haematocrit changes between groups and in-group comparisons. Median (interquartile ranges) haematocrit change was −4 (−6 to −1) in all patients; −5 (−7.8 to −3) in Group R and-3 (−5 to −1) in Group C (P < 0.05). Pre-operative and post-operative lymphocyte, CRP, albumin, creatinine and eGFR changes were not significantly different between groups, but they were significantly different in-group comparisons of pre-operative and post-operative changes (P < 0.05), except eGFR change in Group C [Table 3].
| ¤ Discussion|| |
The results of this study indicate that intra-operative restrictive fluid therapy aims to achieve hospital LOS and ICU admission better than conventional fluid therapy in patients undergoing laparoscopic colorectal cancer surgery. In our study, Group C had 1.5 more hospital LOS days than Group R. Supporting our results, Regenbogen et al. found that hospital LOS was nearly a day greater in the higher fluid administration (6.51 days) group than in the lower fluid administration (5.74 days) group (P < 0.001), and Lobo et al. showed three more hospital LOS days in the standard group than in the restrictive group (P < 0.001)., Likewise to our study, Gomes Izquierdo et al.'s and Myles et al.'s studies found higher hospital LOS in the conservative fluid group than restrictive, with no significant difference., In contrast to our results, Resalt-Pereira et al. showed lower hospital LOS with no significant difference in the group given more fluids (7.1 vs. 8 days). In addition, it was shown that with fluid optimisation even very small reductions in hospital LOS were associated with substantial cost savings.
The second significantly different post-operative outcome of the current study was that Group C showed significantly higher ICU admission rates than Group R, but there was no significant difference in ICU LOS between the groups. Our findings on ICU LOS agree with those reported by Myles et al., who showed no significant difference in ICU LOS between the groups., However, our results differ from those of Gomez et al., who found no significant difference in ICU admission between groups.
The last significantly different outcome was the intra-operative total fluid administration. Intra-operative conventional fluid administration was preferred more than restrictive fluid administration by the anaesthesiologists. Median intra-operative total fluid was significantly different between groups; 2 l and 3 ml/kg/h in Group R; 3 l and 7.2 ml/kg/h in Group C. We expected the significant difference in the total fluids given, excluding the dose comparison, due to the significant weight difference between the groups. Phan et al.'s study showed higher intra-operative fluid volume than our study with a median of 7.06 ml/kg/h in the restrictive group, and 10.7 ml/kg/h in the conservative group. According to the study by Varadhan et al., which classified IV fluid regimens for abdominal surgery as restrictive (<1.75 l/day), balanced (1.75 to 2.75 l/day) and conservative (>2.75 l/day), Group R and Group C were in balanced and conservative groups with the median 2 and 3 l, respectively. Fluid administrations have varied in past studies. Brandstrup et al.'s study used higher intra-operative fluid regimens than our study; standard with median 5.3 l and restricted with 2.7 l. Myles et al. assessed 1307 patients who underwent colorectal surgery in the restrictive group with a mean of 1.6 l and in the conservative group with a mean of 3 l fluid administration. Nisanevich et al.'s study showed lower intra-operative fluid administration in the restrictive group (n = 75, mean = 1.4 l), and higher intra-operative fluid administration in the conservative group (n = 77, mean = 3.8 l). Pereira et al. assessed 128 patients with lower fluid administration than our study; the zero-balanced group had a mean of 1.7 l, haemodynamic optimisation group had a mean of 1.2 l intra-operative fluid administration. Cesur et al. showed the lowest fluid administration in 70 patients in the restrictive and conventional groups, 1.9 and 0.9 l, respectively. Even though conservative fluid administration was found to be safer than restrictive fluid administration, our findings support the use of restrictive or balanced fluid management.
In addition, the pre- to post-operative haematocrit change was significantly different between the groups. The haematocrit change was expected to be higher in Group C, due to the dilution; however, Group R had significantly higher haematocrit change than Group C. Intra-operative bleeding volume was not recorded, we only had the information about not abundant bleeding was occurred in all patients. The reason for this condition was unknown, and more studies are needed. Contrary to our results, previous studies have shown higher post-operative haemoglobin or haematocrit levels in restrictive fluid groups.
In our study, six patients experienced post-operative complications with an 8% ratio. All complications were diagnosed with postoperative ileus. This ratio was lower than the reported in previous studies. The increase in serum albumin concentrations in Group R in the current study was in accordance with previous studies, probably because of the dilution of larger fluid volumes.,
Our study had some limitations. Our study was a retrospective study with a limited number of patients in the groups, due to the surgeries performed in our hospital by one surgeon over 3 years period. Another limitation was that we were not able to use haemodynamic goals, we did not apply a central venous catheter or other haemodynamic monitoring in colorectal surgeries in our daily practice.
| ¤ Conclusions|| |
Intra-operative fluid management was significantly associated with post-operative hospital LOS and ICU admission. Excessive intra-operative fluid management should be avoided in daily practice to improve the outcomes of laparoscopic colorectal surgery. Although our cohort was limited to elective laparoscopic colorectal cancer surgeries, the results further suggest assessing intra-operative restrictive fluid in all elective surgeries. Therefore, more studies are needed to establish the optimal fluid administration during laparoscopic colorectal surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]