Surgery (Austin & Northern Health) - Theses

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Type: PhD thesis × Start date: 2020 × End date: 2021 × Subject: Anaesthesia, surgery, liver, hepatobiliary, pancreas, costs, fluids, complications ×

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    Improving Outcomes in Patients Undergoing Major Hepatobiliary-Pancreatic Surgery
    Weinberg, Laurence ( 2021)
    Background An estimated 300 million surgical procedures are performed each year globally. Postoperative complications are projected to occur in a small percentage of these patients and are associated with increased morbidity and mortality and high health care costs. It is desirable to identify potentially modifiable factors associated with an increased risk of major abdominal surgery complications. The careful use of intravenous fluid and vasoactive medications during surgery are essential modifiable risk factors for reducing the incidence of perioperative complications. The overarching research questions for this thesis are: 1. What are the associations between intraoperative fluid intervention and postoperative outcomes? 2. Does using an intraoperative surgery-specific, patient-specific advanced haemodynamic monitoring algorithm improve postoperative outcomes? 3. What are the costs of complications following major hepatobiliary-pancreatic surgery, and are they associated with the severity of complications? 4. What are the health costs of complications after other major abdominal surgery types, such as colorectal resections, and are they related to the severity of complications? Thirteen clinical studies and six systematic reviews were performed to answer these questions comprehensively: 1. Two retrospective study evaluating fluid amount, type and balance associations, and outcomes in patients undergoing major surgery. 2. Two retrospective observational cohort studies evaluating the effect of a surgery-specific cardiac output-guided haemodynamic algorithm on outcomes in patients undergoing liver resection and pancreaticoduodenectomy. 3. Two prospective randomised clinical trials assess whether a surgery-specific goal-directed therapy protocol improves outcomes in patients undergoing major liver resection and pancreaticoduodenectomy. 4. Two observational cohort studies evaluating the costs of complications in patients undergoing liver and pancreatic surgery. 5. Two systematic reviews assess addressing the costs of complications in patients undergoing hepatobiliary-pancreatic surgery and one integrative review of perioperative fluid management in patients undergoing major hepatic resection. 6. Two studies examine the associations of intrathecal morphine and outcomes after major hepatobiliary surgery. 7. Six other studies (two systematic reviews and 4 retrospective cohort studies) evaluating the costs of complications in patients undergoing major abdominal surgery. Results 1. There is a significant independent association between liberal fluid volumes and developing complications in patients undergoing major surgery. 2. Using a perioperative haemodynamic optimisation plan that prioritises preserving cardiac output and organ perfusion pressure by carefully using fluid therapy, vasoactive drugs and the timely application of inotropic drugs improve postoperative outcomes in patients undergoing pancreaticoduodenectomy. Larger studies are needed to confirm this finding. 3. In patients undergoing major liver resection in high-volume hepatobiliary surgical units, adding a fluid restrictive intraoperative cardiac output-guided algorithm with a standard Enhanced Recovery After Surgery (ERAS) protocol did not significantly reduce the hospital stay length or fluid-related complications. These findings are hypothesis-generating, and a larger confirmatory study is justified. 4. Major abdominal surgery carries a high incidence of complications, resulting in a substantial financial burden. 5. Hospital costs and length of stays increase with greater severity and number of complications. 6. Patients with the lowest haemoglobin concentrations incurred the highest hospital costs, strongly associated with increased blood transfusions. 7. In patients undergoing open liver resection and intrathecal morphine, in addition to conventional multimodal analgesic strategies, reduced postoperative opioid requirements and improved analgesia for twenty-four hours after surgery. This occurred without any statistically significant differences in opioid-related complications and length of hospital stay. Conclusion Findings of this thesis imply that the careful use of fluid and vasoactive medications is a core component of improving adverse outcomes after surgery. Clinicians should employ advanced haemodynamic monitoring to help rationalise the effective use of fluid and vasoactive medications. Further, these findings provide an in-depth analysis of the rate of complications that occur after major surgery. Moreover, these findings imply that complications following major surgery are common and associated with increased costs. The impact of complications on cost has a dose-response relationship to both the amount and severity of complications. This thesis highlights the importance of evaluating and preventing complications in the postoperative period. Finally, these findings allow health institutions to review their practices in addressing complications and their associated cost and encourages further studies to expand on potential identification and mitigation strategies to address complications and costs in the future.