Clinical implications of intraoperative fluid therapy in pancreatic surgery: it is not “just water”

Abstract

Background: Recent studies have suggested that intraoperative fluid overload is associated with a worse outcome after major abdominal surgery. However, evidence in the field of pancreatic surgery is still not consistent. The aim of this study was to evaluate whether intraoperative fluid management could affect the outcome of a major pancreatic resection. Methods: Prospective analysis of 350 major pancreatic resections performed in 2016 at The Pancreas Institute, University of Verona Hospital Trust. Patients were dichotomized according to intraoperative fluid volume administration into near-zero fluid balance (NZF - infusion rate 3 mL/kg/h) and liberal fluid balance groups (LF - >3 mL/kg/h). Intraoperative fluid administration was then correlated to the postoperative outcome. Results: Overall, a LF balance was associated with an increased rate of Clavien-Dindo IIIB (50.5% vs. 34.5%; p = 0.02) and delayed gastric emptying (DGE) (8.8% vs. 1.8%; p = 0.05). A NZF balance was associated with a reduced incidence of biliary fistula (0% vs. 7.9%; p = 0.05) and DGE (5% vs. 11.6%; p = 0,04) but an increased rate of post-operative acute pancreatitis (75% vs. 49.2%; p = 0.02) after pancreaticoduodenectomy. Considering patients with a soft pancreatic remnant, a NZF balance was associated with an increased rate of pancreatic fistula (60% vs. 45.2%, p = 0.02). Conclusion: Considering all pancreatic resections, a LF balance is associated with an increased rate of postoperative morbidity. However, in the case of PD with a soft pancreas, a NZF balance could lead to pancreatic stump ischemia and anastomotic failure. Intraoperative fluid management should be managed according to patient's pancreas-specific risk factors.