Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
Dis Esophagus. 2021 Jul 12;34(7). doi: 10.1093/dote/doaa111.
The optimal perioperative fluid management during esophagectomy is still not clear. Liberal regimens have been associated with higher morbidity and respiratory complications. Restrictive regimens might raise concerns for kidney function and increase the need to associate vasopressors. The aim of this study was to investigate retrospectively the perioperative fluid administration during esophagectomy and to correlate this with postoperative respiratory outcome. All patients who underwent esophagectomy between January and December 2016 were retrospectively analyzed. Patient characteristics, type of surgery and postoperative course were reviewed. Fluid administration and vasopressor use were calculated intraoperatively and during the postoperative stay at the recovery unit. Fluid overload was defined as a positive fluid balance of more than 125 mL/m2/h during the first 24 hours. Patients were divided in 3 groups: GRP0 (no fluid overload/no vasopressors); GRP1 (no fluid overload/need for vasopressors); GRP2 (fluid overload with/without vasopressors). Postoperative complications were prospectively recorded according to Esophagectomy Complications Consensus Group criteria. A total of 103 patients were analyzed: 35 (34%) GRP0, 50 (49%) GRP1 and 18 (17%) GRP2. No significant differences were found for age, treatment (neoadjuvant vs. primary), type of surgery (open/minimally invasive), histology nor comorbidities. There were significant (P ≤ 0.001) differences in fluid balance/m2/h (75 ± 21 mL; 86 ± 22 mL and 144 ± 20 mL) across GRP0, GRP1 and GRP2, respectively. We found differences in respiratory complications (GRP0 (20%) versus GRP1 (42%; P = 0.034) and GRP0 (20%) versus GRP2 (61%; P = 0.002)) and "Comprehensive Complications Index" (GRP0 (20.5) versus GRP1 (34.6; P = 0.015) and GRP0 (20.5) versus GRP2 (35.1; P = 0.009)). Multivariable analysis (binary logistic regression) for "any respiratory complication" was performed. Patients who received fluid overload (GRP2) had a 10.24 times higher risk to develop postoperative respiratory complications. When patients received vasopressors alone (GRP1), the chances of developing these complications were 3.57 times higher compared to GRP0. Among patients undergoing esophagectomy, there is a wide variety in the administration of fluid during the first 24 hours. There was a higher incidence of respiratory complications when patients received higher amounts of fluid or when vasopressors were used. We believe that a personalized and protocolized fluid administration algorithm should be implemented and that individual risk factors should be identified.
在食管癌手术中，最佳围手术期液体管理仍不明确。大量输液与更高的发病率和呼吸并发症相关。限制输液可能会引起肾功能的担忧，并增加使用血管加压素的需求。本研究旨在回顾性分析食管癌手术期间的围手术期液体管理，并将其与术后呼吸结果相关联。回顾性分析了 2016 年 1 月至 12 月期间接受食管癌切除术的所有患者。回顾了患者特征、手术类型和术后恢复单元的病程。术中及术后恢复单元计算了液体输注和血管加压素的使用。将液体超负荷定义为前 24 小时内每平方米超过 125 毫升/小时的正液体平衡。患者分为 3 组：GRP0（无液体超负荷/无血管加压素）；GRP1（无液体超负荷/需要血管加压素）；GRP2（液体超负荷伴/不伴血管加压素）。根据食管癌并发症共识组标准，前瞻性记录术后并发症。共分析了 103 例患者：35 例（34%）为 GRP0，50 例（49%）为 GRP1，18 例（17%）为 GRP2。年龄、治疗（新辅助治疗与原发性治疗）、手术类型（开放/微创）、组织学和合并症均无显著差异。GRP0、GRP1 和 GRP2 之间的液体平衡/平方米/小时（75±21ml；86±22ml 和 144±20ml）存在显著差异（P≤0.001）。我们发现呼吸并发症（GRP0（20%）与 GRP1（42%；P=0.034）和 GRP0（20%）与 GRP2（61%；P=0.002））和“综合并发症指数”（GRP0（20.5）与 GRP1（34.6；P=0.015）和 GRP0（20.5）与 GRP2（35.1；P=0.009））存在差异。对“任何呼吸并发症”进行了多变量分析（二元逻辑回归）。接受液体超负荷（GRP2）的患者发生术后呼吸并发症的风险增加 10.24 倍。当患者仅接受血管加压素（GRP1）时，发生这些并发症的几率是 GRP0 的 3.57 倍。在接受食管癌切除术的患者中，前 24 小时内的液体输注量存在很大差异。当患者接受更多的液体或使用血管加压素时，呼吸并发症的发生率更高。我们认为，应该实施个性化和规范化的液体管理算法，并确定个体的危险因素。
