Perioperative Net Fluid Balance Predicts Pancreatic Fistula
Leah K. Winer
Vikrom K. Dhar
Tiffany C. Lee
Mackenzie C. Morris
Shimul A. Shah
Syed A. Ahmad
Sameer H. Patel
Received: 5 April 2018 /Accepted: 9 May 2018
2018 The Society for Surgery of the Alimentary Tract
Background Our goal was to evaluate the relationship between perioperative fluid administration and the development of
clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).
Methods Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between
2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance.
Results POPF was identified in 17.3% of patients (n = 18). No significant demographic differences were identified among
tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time,
blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with
high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4%
vs. 11.4% vs. 8.8%, p = 0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR
1.26, CI 1.03–1.55, p =0.03).
Conclusion High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD
morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.
Postoperative pancreatic fistula
Postoperative pancreatic fistula (POPF) is one of the most
common complications following pancreaticoduodenectomy
(PD), occurring after 3–45% of cases at high-volume
Classification of POPF is based on clinical sever-
ity. While biochemical leaks (BL) are mostly transient and
asymptomatic, clinically relevant grades B or C POPF (CR-
POPF) can lead to abscess, hemorrhage, delayed gastric emp-
tying, multiorgan dysfunction, need for prolonged drainage
and subsequent interventions, or death.
their associated increase in hospitalization cost, length of stay
(LOS), and readmission, CR-POPFs remain a significant
source of morbidity and mortality after PD.
Predictors of POPF include a soft gland, a small or poste-
riorly located pancreatic duct, pathology, intraoperative esti-
mated blood loss (EBL), male sex, body mass index (BMI),
and surgeon inexperience.
Over the past decades, numer-
ous studies have emerged investigating optimal
pancreaticoenteric reconstruction techniques
and the role
of adjuncts, such as stents, sealants, patches, drains, and so-
Despite increased recognition of risk,
wide adoption of mitigating strategies, and performance of PD
by high-volume surgeons, there has been only minimal im-
provement in POPF rates following PD.
With the emergence of the Enhanced Recovery After
Surgery (ERAS) Society and an outpouring of data about the
dangers of excessive intravenous fluid (IVF), interest has
shifted toward the study of perioperative fluid administration
Presentation This paper was presented at the 2018 Americas Hepato-
Pancreato-Biliary Association (AHPBA) Annual Meeting and is being
submitted as an original article.
* Sameer H. Patel
Cincinnati Research on Outcomes and Safety in Surgery (CROSS),
Department of Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA
Section of Surgical Oncology, Department of Surgery, University of
Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558),
Cincinnati, OH 45267-0558, USA
Journal of Gastrointestinal Surgery