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Observational Study
. 2017 Mar 2;12(3):e0172806.
doi: 10.1371/journal.pone.0172806. eCollection 2017.

Effect of goal-directed therapy on outcome after esophageal surgery: A quality improvement study

Denise P Veelo  1 , Mark I van Berge Henegouwen  2 , Kirsten S Ouwehand  1 , Bart F Geerts  1 , Maarten C J Anderegg  2 , Susan van Dieren  1   2 , Benedikt Preckel  1 , Jan M Binnekade  3 , Suzanne S Gisbertz  2 , Markus W Hollmann  1
Affiliations
Observational Study

Effect of goal-directed therapy on outcome after esophageal surgery: A quality improvement study

Denise P Veelo et al. PLoS One. .

Abstract

Background: Goal-directed therapy (GDT) can reduce postoperative complications in high-risk surgery patients. It is uncertain whether GDT has the same benefits in patients undergoing esophageal surgery. Goal of this Quality Improvement study was to evaluate the effects of a stroke volume guided GDT on post-operative outcome.

Methods and findings: We compared the postoperative outcome of patients undergoing esophagectomy before (99 patients) and after (100 patients) implementation of GDT. There was no difference in the proportion of patients with a complication (56% vs. 54%, p = 0.82), hospital stay and mortality. The incidence of prolonged ICU stay (>48 hours) was reduced (28% vs. 12, p = .005) in patients treated with GDT. Secondary analysis of complication rate showed a decrease in pneumonia (29 vs. 15%, p = .02), mediastinal abscesses (12 vs. 3%, p = .02), and gastric tube necrosis (5% vs. 0%, p = .03) in patients treated with GDT. Patients in the GDT group received significantly less fluids but received more colloids.

Conclusions: The implementation of GDT during esophagectomy was not associated with reductions in overall morbidity, mortality and hospital length of stay. However, we observed a decrease in pneumonia, mediastinal abscesses, gastric tube necrosis, and ICU length of stay.

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Conflict of interest statement

Competing Interests: DV and MH have received a research grant (contract was made, under name: quality improvement project, AMC) from Edwards Lifesciences. DV, SS, BG and MBH have done consultancy work for Edwards Lifesciences, including travel reimbursement. BP has received a grant from Edwards, but this was not related to this project. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Intraoperative GDT algorithm.
During the operation additional colloid boluses were given only when SV declined more than 10% below optimum (trigger SV). If SV fell below trigger during periods of decreased venous return such as pneumoperitoneum and reversed Trendelenburg and did not increase after one or two fluid boluses, (and no bleeding existed), the patient was considered not fluid responsive. Other hemodynamic goals were: MAP > 65 mmHg or < 20% change from baseline MAP. Hypotensive episodes were initially treated with Phenylefrine and/or Ephedrine. If lasting, Norepinephrine infusion was started.
Fig 2
Fig 2. Consort diagram.
We excluded patients where FloTrac was not connected (because of arrhythmia), those came for isolated esophageal salvage surgery with neo-esophagus reconstruction only (stage T4b tumor with extensive chemo-radiotherapy) and those in whom surgery was stopped prematurely because of the presence of metastases.
Fig 3
Fig 3. Box and whisker plot of fluid balances and type of fluids used in the GDT and the standard group.
The use of crystalloids (Cr), colloids (Co), intra-operative (B1) fluid balance and cumulative balance at dismissal to the ward (B2) are shown. GDT; goal-directed fluid therapy. Boxes represent interquartiles with whiskers showing 10–90% ranges.
See this image and copyright information in PMC

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