The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy.

INTRODUCTION: Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying. METHODS: Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12. RESULTS: Of 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%). CONCLUSION: Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.

Current State of Enhanced Recovery After Surgery in Hepatopancreatobiliary Surgery.

For over two decades, enhanced recovery pathways have been implemented in many surgical disciplines, most notably in colorectal surgery. Since 2001, the Enhanced Recovery After Surgery (ERAS®) Study Group has developed a main protocol comprising 24 evidence-based core items. While these core items unite similar preoperative, intraoperative, and postoperative principles across surgical subspecialties, variations and modifications exist to these core items based on unique considerations for each surgical subspecialty. This overview will summarize overarching principles for ERAS within hepatopancreaticobiliary (HPB) surgery, first summarizing Pancreaticoduodenectomy and Hepatectomy ERAS Society Guidelines. Specifically, principles and areas of current debate regarding preoperative oral carbohydrate loading/fasting, perioperative fluid management, and analgesia will be discussed. While institutions are beginning to realize both clinical and financial benefits of ERAS within HPB surgery, enhanced recovery remains a relatively recent phenomenon within the field. The complex patient population, high morbidity, and resource-intensive care involved in HPB surgery certainly warrant special consideration. To continue to promote improved clinical outcomes in a cost-effective manner, the ERAS Society will continue to actively address concerns and ensure all recommendations are based on the most up-to-date scientific evidence within the field of HPB surgery.