Anthony J. Senagore

No consensus exists regarding the optimal fluid (crystalloid or colloid) or strategy (liberal, restricted, or goal directed) for fluid management after colectomy. Prior assessments have used normal saline. This is the first assessment of standard, goal-directed perioperative fluid management with either lactated Ringer’s or hetastarch/lactated Ringer’s, with use of esophageal Doppler for guidance, in laparoscopic colectomy with an enhanced recovery protocol. A double-blinded, prospective, randomized, three-armed study with Institutional Review Board approval was used for patients undergoing laparoscopic segmental colectomy assigned to the standard, goal-directed/lactated Ringer’s and goal-directed/hetastarch groups. A standard anesthesia and basal fluid administration protocol was used in addition to the goal-directed strategies guided by esophageal Doppler. Sixty-four patients undergoing laparoscopic colectomy (22 standard, 21 goal-directed/lactated Ringer’s, 21 goal-directed/hetastarch) had similar operative times (standard, 2.3 hours; goal-directed/lactated Ringer’s, 2.5 hours; goal-directed/hetastarch, 2.3 hours). The lactated Ringer’s group received the greatest amount of total and milliliters per kilogram per hour of operative fluid (standard, 2,850/18; goal-directed/lactated Ringer’s, 3,800/23; and goal-directed/hetastarch, 3,300/17; P < 0.05). The hetastarch group had the longest stay (standard, 64.9 hours; goal-directed/lactated Ringer’s, 71.8 hours; goal-directed/hetastarch, 75.5 hours; P < 0.05). The standard group received the greatest amount of fluid during hospitalization (standard, 2.5 ml/kg/h; goal-directed/lactated Ringer’s, 1.9 ml/kg/h; goal-directed/hetastarch, 2.1 ml/kg/h; P < 0.05). There was one instance of operative mortality in the goal-directed/hetastarch group. Goal-directed fluid management with a colloid/balanced salt solution offers no advantage and is more costly. However, goal-directed, individualized intraoperative fluid management with crystalloid should be evaluated further as a component of enhanced recovery protocols following colectomy because of reduced overall fluid administration.

We used a publicly available limited data set from the National Surgical Quality Improvement Project to assess the preoperative risk factors and postoperative complication rates reported for laparoscopic colectomy and open colectomy. Patients were evaluated from this nationally reported database who underwent either laparoscopic colectomy (n = 2728) or open colectomy (n = 4719) from December 1, 2005 through September 1, 2007. Body mass index was similar for laparoscopic (27.9, SD 5.8) and open colectomy patients (28.0, SD 7.2). The open colectomy group had significantly higher rates of diabetes (16.0 percent vs. 12.0 percent), smoking (18.0 percent vs. 15.0 percent), dyspnea (14.0 percent vs. 9.0 percent), chronic obstructive pulmonary disease (7.0 percent vs. 4.0 percent), congestive heart failure (2.0 percent vs. 0.6 percent), myocardial infarction within previous 6 months (0.9 percent vs. 0.4 percent), and hypertension (54 percent vs. 50 percent). All perioperative complications were more frequent in the open colectomy group; mortality (4.9 percent vs. 0.8 percent), surgical site infections (12 percent vs. 8.0 percent), wound disruption (2.0 percent vs. 0.8 percent), pneumonia (5.0 percent vs. 2.0 percent), and acute renal failure (1.0 percent vs. 0.3 percent). The data, derived from the publicly available limited data set from the National Surgical Quality Improvement Project audit process, suggest a higher rate for all commonly identified complications for open compared to laparoscopic colectomy; however, open colectomy patients have an apparent higher preoperative risk.