Intraoperative hemodynamic management during pancreatoduodenectomy – an analysis of 525 patients

Abstract

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.