To the Editor:
We read the article by Arslan-Carlon et al.1 with great interest. The authors are to be congratulated for their research on the impact of fluid therapy on postoperative ileus. In this recent randomized, controlled trial including 283 patients, they found no difference in the incidence of postoperative ileus between patients treated with a goal-directed therapy compared with a standard procedure in a homogenous open radical cystectomy patient cohort from a high caseload center.
The pathogenesis of postoperative ileus is clearly multifactorial (fluid overload, opioids, neurohormonal dysregulation, gastrointestinal stretch, inflammatory response).2,3 In the era of enhanced recovery protocols including multiple preoperative, intraoperative, and postoperative optimization steps, it is not surprising to find that intraoperative goal-directed therapy alone has no impact on the return of bowel function compared with a moderate liberal fluid standard fluid administration. Furthermore, it remains questionable whether postoperative fluid substitution should be uniformly managed in patients who received either an intraoperative goal-directed therapy or a restrictive or relatively liberal fluid administration. Indeed, in this study net fluid during the hospitalization was higher in the standard group (−1,986 ml vs. −1,296 ml) but resulted in similar maximum body weight changes (2.7 kg vs. 3.0 kg) and could be interpreted as the consequence of a more aggressive diuretic therapy in the standard group postoperatively. This is of importance because postoperative submucosal edema has been postulated as a risk factor for a delayed return of gastrointestinal function.3 Unfortunately, the authors did not give any information on the postoperative administration of diuretics.
The problem of adequate terminology is another ongoing issue. We were surprised by the authors’ comment in the discussion that the term constipation was not adequately described in the article by Wuethrich et al., as both the term constipation as well as the term ileus were defined in the appendix. Constipation was defined as no passage of stool without signs of ileus by postoperative day 5 and could be considered similar to what was considered a primary postoperative ileus in the article by Arslan-Carlon et al. This definition was based on the nomenclature resulting from a well-performed case series analysis aiming to standardize complications after cystectomy from the Department of Urology at the Sloan-Kettering Cancer Center (New York, New York).5 Perhaps the authors could specify why they did not apply their own above-mentioned definition in the present study. We recognize that the publication by Shabsigh et al. is more than 10 yr old, but the goal of a good standardized reporting methodology should be its continued long-term applicability. The Clavien Dindo classification remains the best example hereof.4,6 In the context of prevention of postoperative ileus, it would also be interesting to know which opioid antagonist was administered subcutaneously perioperatively.
Finally, no data are presented about the systemic administration of opioids, a known risk factor for delayed return of bowel function. We only learn that patients received an epidural analgesia with a mixture containing a very low dose of bupivacaine (0.05%) and a relatively high dosage of opioid (8 μg/ml hydromorphone).
In conclusion, the saying “one size does not fit all” can also be applied to fluid therapy. This study is of importance because it shows no benefit of goal-directed therapy in terms of reducing gastrointestinal-related complication rates. A more selective and differentiated approach in fluid management is needed. In some cases, restrictive fluid therapy may be beneficial, and in other cases, a modestly liberal fluid administration resulting in a postoperative weight gain of approximately 2 to 3 kg would make no difference in outcome. Fluid management is only part of a complex battery of interventions affecting outcome after open radical cystectomy.
The authors declare no competing interests.