Use of mannitol as a measure to prevent postoperative renal failure in patients with obstructive jaundice

Modified reconstruction approach after pancreaticoduodenectomy optimizes postoperative outcomes: Results from a multivariate cohort analysis

Despite technical advances in recent decades and a decrease in hospital mortality (<5%), pancreaticoduodenectomy (PD) is still associated with major postoperative complications, even in high-volume centers. The present study aimed to assess the effect of a modified reconstruction technique on postoperative morbidity and mortality. A cohort study of all patients (n=218) undergoing PD between January 2010 and December 2019 was performed at Attikon University Hospital (Athens, Greece). Several variables were studied, including demographic data, past medical history, perioperative parameters, tumor markers and pathology, duration of hospitalization, postoperative complications, 30-day-survival, postoperative mortality and overall survival using multivariate logistic regression and survival analysis techniques. In this cohort, 123 patients [modified PD (mPD) group] underwent a modified reconstruction after a pylorus-preserving pancreaticoduodenectomy, which consisted of gastrojejunostomy and pancreaticojejunostomy on the same loop and an isolated hepaticojejunostomy on another loop. In the standard PD (StPD) group, 95 patients underwent standard reconstruction. The median age was 67 years, ranging from 25 to 89 years. Compared with in the StPD group, the mPD group had significantly lower rates of grade B and C pancreatic fistula (4.9% vs. 28.4%), delayed gastric emptying (7.3% vs. 42.1%), postoperative hemorrhage (3.3% vs. 20%), intensive care unit admission (8.1% vs. 18.9%), overall morbidity (Clavien-Dindo grade III-V: 14.7% vs. 42.0%), perioperative mortality (4.1% vs. 14.7%), and shorter hospitalization stay (11 days vs. 20 days). However, no difference was noted regarding median survival (35 months vs. 30 months). In this single-center series, a modified reconstruction after PD appears to be associated with improved postoperative outcomes. However, further evaluation in larger multi-center trials is required.

Fluids for Prevention and Management of Acute Kidney Injury

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.

Renal function and dysfunction

Recent publications regarding perioperative renal dysfunction provide a 'potpourri' of topics worthy of discussion. The risk of perioperative renal dysfunction is higher in patients with heart failure, but other pre-existing conditions, such as genetic polymorphism, may have prognostic implications. Evaluation of renal risk and protective interventions are discussed for a number of specific operative entities, including cardiac surgery (with or without cardiopulmonary bypass), aortic surgery and renal revascularization. New publications on a wide variety of nephrotoxic insults are presented, including antifibrinolytic agents, obstructive jaundice, prostaglandin inhibitors, cyclosporine A, radiocontrast dyes and volatile anesthetic agents. Renal transplantation is discussed as a specific entity. Finally, we discuss recent papers describing outcome in patients in chronic renal failure undergoing cardiac surgery.