Individualized Perioperative Blood Pressure and Fluid Therapy in Esophagectomy: A Prospective, Single-blind Randomized Controlled Trial.

Abstract

Esophagectomy is a key treatment for esophageal cancer but carries a high risk of postoperative complications, some of which are potentially preventable through optimized hemodynamic management. Goal-directed fluid therapy individualizes cardiac output targets but often applies fixed blood pressure thresholds and is discontinued before major postoperative fluid shifts occur. Extending goal-directed fluid therapy into the postoperative period with individualized blood pressure thresholds may address these limitations. In this single-center, prospective, blinded, randomized controlled trial, patients undergoing esophagectomy were randomized 1:1 to either extended goal-directed fluid therapy or standard care. In the extended goal-directed fluid therapy group, cardiac output was optimized and mean arterial pressure threshold was the individual patient's nighttime baseline. The protocol continued from tracheal intubation through to 7:00 am the following morning. The primary outcome was total postoperative morbidity, measured by the Comprehensive Complication Index at day 30. Of 100 patients (49 extended goal-directed fluid therapy group, 51 standard group), extended goal-directed fluid therapy was associated with a higher fluid balance (2,517 ± 1,194 ml vs. 2,001 ± 1,114 ml; mean difference, 516 ml; 95% CI, 57 to 974; P = 0.028), increased norepinephrine use (median, 7,894 μg [interquartile range, 3,946-13,793] vs. 4,611 μg [interquartile range, 2,138 to 7,296]; P < 0.001), and higher mean arterial pressure (mean difference, 3 mmHg; 95% CI, 1 to 5; P = 0.011). At day 30, the mean Comprehensive Complication Index did not differ between groups (39.0 ± 20.0 vs. 39.2 ± 21.0; mean difference, -0.2; 95% CI, -8.6 to 8.1; P = 0.95). Despite achieving protocol-driven treatment differences, extended and individualized goal-directed fluid therapy did not reduce postoperative complications after esophagectomy.