Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial.

BACKGROUND: More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS: In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS: In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION: Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION: EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).

Enteral Antibiotics are Non-inferior to Intravenous Antibiotics After Complicated Appendicitis in Adults: A Retrospective Multicentre Non-inferiority Study.

BACKGROUND: Prolonging post-operative antibiotic treatment beyond 3 days does not seem to reduce the incidence of post-operative abscess formation or wound infection after surgery for complicated appendicitis. The route of administration seems to be based on an empirical basis. Using enteral antibiotics could reduce length of stay and reduce overall costs. We aimed to examine whether treatment with enteral antibiotics during the first three post-operative days is non-inferior to intravenous antibiotics regarding intra-abdominal abscess formation or wound infection after surgery for complicated appendicitis. METHODS: A retrospective study of adult patients having surgery for complicated appendicitis within a period of 32 months in the Capital Region of Denmark. Primary outcome was the incidence of post-operative abscess formation, and secondary outcome was wound infections, both within 30 days of surgery. Route of antibiotic administration for the first three post-operative days was registered for all patients. RESULTS: A total of 1141 patients were included in the study. The overall risk of developing an intra-abdominal abscess was 6.7% (95% CI 5.2%; 8.1%), and the risk of wound infection was 1.2% (95% CI 0.6%; 1.8%). In a multivariate intention-to-treat analysis, patients treated post-operatively with enteral antibiotics had an odds ratio of 0.78 (95% CI 0.41; 1.45, p = 0.429) for developing an intra-abdominal abscess and an odds ratio of 0.86 (95% CI 0.17; 4.29, p = 0.851) for developing a wound infection compared to patients treated post-operatively with intravenous antibiotics. CONCLUSION: Treatment with enteral antibiotics was non-inferior compared to treatment with intravenous antibiotics during the first 3 days after surgery for complicated appendicitis.

[Lifestyle interventions affect the surgical outcome].

Observational studies have shown that poor nutritional status or obesity, smoking, alcohol drinking/abuse, and physical fitness are associated to a variety of poor surgical outcomes. Interventional studies show some effect of preoperative smoking cessation, alcohol abstinence, perioperative alcohol intervention, and exercise on wound healing and infectious outcomes. Patients scheduled for benign surgery should be encouraged to smoking cessation and alcohol abstinence. Evidence on other lifestyle interventions, vulnerable patients and acute surgical settings is still lacking.