Intraoperative hemodynamic management during pancreatoduodenectomy - an analysis of 525 patients

IMPORTANCE

Optimization of perioperative hemodynamic management during major pancreatic surgery can reduce postoperative complications.

OBJECTIVE

In this study, we aimed to investigate the effect of intraoperative hemodynamic management, in consideration of both anesthesiologic and surgery-related aspects on major short-term complications following partial pancreatoduodenectomy (PD).

DESIGN, SETTING AND PARTICIPANTS

Data of 525 patients undergoing PD between January 2017 and December 2018 at the Heidelberg University Hospital were retrospectively analyzed.

MAIN OUTCOMES AND MEASURES

Primary outcome was a composite of 90-day mortality, pancreatic fistula and completion pancreatectomy. Logistic regression was performed to estimate the impact of anesthesiologic and surgical factors. Furthermore, patients were stratified by the amount of fluid administered intraoperatively and the maximum catecholamine dose to examine the impact on the primary endpoint.

RESULTS

Using logistic regression analysis we demonstrated that epidural anesthesia was associated with a reduction in the occurrence of the combined endpoint (OR 0.568; CI 0.331-0.973), this effect was primarily driven by a lower rate of completion pancreatectomy. The intraoperative administration of fresh frozen plasma (FFP) doubled the odds of the occurrence of the primary endpoint (OR 2.238; CI 1.290-3.882). The comparison of patients with and without FFP transfusion showed that all components of the primary endpoint were more frequent in the FFP group. Complication rates in the stratified fluid groups showed a U-shaped curve with the least amount of complications in patients who received 6.5 to 8 ml/kg/h of intraoperative fluid. The comparison of maximum norepinephrine doses revealed the same pattern with the least complication rate in the low-intermediate dose range (0.05-0.08 µg/kg/min and 0.08-0.11 µg/kg/min).

CONCLUSIONS AND RELEVANCE

Epidural anesthesia had a beneficial effect on the rate of major surgical complications following PD, whereas intraoperative FFP transfusion showed a negative association. Intraoperative hemodynamic management appears to have a major impact on perioperative mortality and morbidity with a U-shaped relation for both fluid and vasopressor dose.

Perioperative changes in hemoglobin levels during major hepatopancreatic surgery in transfused and non-transfused patients

Background:

Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations.

Methods:

Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time.

Results:

The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion.

Conclusions:

Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.

Blood utilization and clinical outcomes in pancreatic surgery before and after implementation of patient blood management

BACKGROUND

Over the past decade, patient blood management (PBM) programs have been developed to reduce allogeneic blood utilization. This is particularly important in pancreatic surgery, which has historically been associated with high transfusion requirements and morbid event rates. This study investigated blood utilization and clinical outcomes in pancreatic surgery before, during, and after the implementation of PBM.

STUDY DESIGN AND METHODS

A total of 3482 pancreatic surgery patients were assessed in a 10-year retrospective cohort study (2009-2019) at a single academic center. Baseline patient characteristics, transfusion practices, postoperative morbidity (infectious, thrombotic, ischemic, respiratory, and renal complications), mortality, and length of stay were compared between patients in the pre-PBM (2009-2013), early-PBM (2014-2016), and mature-PBM (2017-2019) time periods. Multivariable analysis assessed the odds for composite morbidity/mortality.

RESULTS

Comparing the mature-PBM to pre-PBM cohorts, transfused units per 100 discharged patients decreased by 53% for erythrocytes (155 to 73; P < .0001), 81% for plasma (79 to 15; P < .038), and 75% for platelets (10 to 2.5; P < .005). Clinical outcomes improved as well, with composite morbid event rates decreasing by more than 50%, from 236 in 1438 patients (16.4%) to 85 in 1145 patients (7.4%) (P < .0001). Mortality and length of stay remained unchanged. Compared to the pre-PBM time period, early-PBM was associated with a risk-adjusted decrease in composite morbidity/mortality (OR 0.73; 95% CI 0.57-0.93; P = .010), while mature-PBM demonstrated a further incremental decrease (OR 0.44; 95% CI 0.33-0.57; P < .0001).

CONCLUSIONS

The implementation of PBM was associated with substantially decreased blood utilization in pancreatic surgery, without negatively impacting clinical outcomes.