Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients
Glatz et al. BMC Surgery
Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients
Torben Glatz 0
Birte Kulemann 0
Goran Marjanovic 0
Svenja Bregenzer 0
Frank Makowiec 0
Jens Hoeppner 0
0 Department of General and Visceral Surgery, Medical Center - University of Freiburg and Faculty of Medicine - University of Freiburg , Hugstetter Str. 55, D-79106 Freiburg , Germany
Background: Restrictive intraoperative fluid management is increasingly recommended for patients undergoing esophagectomy. Controversy still exists about the impact of postoperative fluid management on perioperative outcome. Methods: We retrospectively examined 335 patients who had undergone esophagectomy for esophageal cancer at the University Hospital Freiburg between 1996 and 2014 to investigate the relation between intra- and postoperative fluid management and postoperative morbidity after esophagectomy. Results: Perioperative morbidity was 75%, the in-hospital mortality 8%. A fluid balance above average on the operation day was strongly associated with a higher rate of postoperative mortality (21% vs 3%, p < 0.001) and morbidity (83% vs 66%, p = 0.001). Univariate analysis for risk factors for adverse surgical outcome (Clavien ≥ III) identified ASA-score (p = 0.002), smoking (p = 0.036), reconstruction by colonic interposition (p = 0.036), cervical anastomosis (p = 0.017), blood transfusion (p = 0.038) and total fluid balance on the operation day and on POD 4 (p = 0.001) as risk factors. Multivariate analysis confirmed only ASA-score (p = 0.001) and total fluid balance (p = 0.001) as independent predictors of adverse surgical outcome. Conclusion: Intra- and postoperative fluid overload is strongly associated with increased postoperative morbidity. Our results suggest restrictive intra- and especially postoperative fluid management to optimize the outcome after esophagectomy.
Esophageal cancer; Esophagectomy; Perioperative fluid management; Morbidity; Adverse surgical outcome
Surgery for esophageal cancer has traditionally been
associated with high postoperative morbidity and mortality and
poor long-term survival, but results have improved
dramatically over the last decade [1, 2]. Improvements in
perioperative management and surgical technique have contributed
to a reduced rate of surgical and medical complications, but
the impact of each individual factor remains vague.
Among other factors, restrictive intraoperative fluid
management has proven to reduce perioperative
morbidity in colorectal and pancreatic surgery . While
nowadays restrictive intraoperative fluid management is
accepted as favourable in esophageal surgery as well as
in other major abdominal operations , very little
evidence exists supporting this regimen, and even less
concerning the early postoperative phase. Small studies
were able to establish a correlation between
intraoperative fluid overload and increased postoperative
pulmonary morbidity as well as an increased number of surgical
complications after esophageal surgery [5–7]. These
studies are however limited due to very small numbers
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of patients, their retrospective study design and short
To date no study provides sufficient evidence
supporting restrictive intra- and postoperative fluid management
after esophagectomy. The aim of this study was thus to
evaluate risk factors for surgical and pulmonary morbidity
focusing on the impact of intraoperative and especially
postoperative fluid management.
This study evaluates the outcome of 335 consecutive
patients with esophageal cancer undergoing
esophagectomy between 01/1996 and 03/2014 at a high-volume
tertiary referral centre. Our primary Hypothesis was that
restrictive postoperative fluid management is associated
with a reduced postoperative morbidity. Informed
consent was obtained from all patients before their inclusion
in the cancer registry. The Medical Ethics Committee of
the University of Freiburg approved the study.
Pretherapeutic work-up and multimodal treatment
Diagnostic work-up included endoscopy with biopsies
and thoraco-abdominal computerized tomography (CT)
in all patients, as well as cardiac and pulmonary
workup. Endoscopic ultrasound was used routinely for
locoregional staging if technically possible. In general, lymph
nodes were preoperatively classified as malignant if >1 cm
by computerized tomography or endoscopic ultrasound.
PET-CT was reserved for diagnostic nondestinctive cases.
Neoadjuvant chemoradiation has been performed since
1994 when (after initial staging) the T stage was T3 or T4
and/or lymph nodes were suspected to be positive, and
patients had no other medical contraindication for
neoadjuvant chemoradiation. Neoadjuvant chemoradiation was
performed according to a protocol suggested by Naunheim
et al.  or the CROSS protocol . Radiation dose was
increased from 36 GY to 45 Gy after 2011.
Neoadjuvant chemotherapy has been performed since
2006 in patients with Adenocarcinoma (AC) of the
distal esophagus and esophagogastric junction if the T
stage was T3 or T4 and/or lymph nodes were suspected
to be positive, and patients had no other medical
contraindication for neoadjuvant chemotherapy.
Neoadjuvant chemotherapy was performed according to the
protocol suggested by Cunningham et al.  or the
FLOT protocol . All neoadjuvant chemotherapy
protocols were scheduled for postoperative continuance
starting 4–8 weeks after the operation with the same
drug composition and dosage as preoperatively.
After neoadjuvant chemoradiation or neoadjuvant
chemotherapy, the patients were restaged by endoscopy
and CT, and resection was performed approximately 6
weeks after the end of neoadjuvant treatment.
The operative procedure was chosen according to tumor
location. Patients were mostly operated by an Ivor-Lewis
thoraco-abdominal approach (right-sided thoracotomy,
median laparotomy, collar hand-sewn or intrathoracic
stapled anastomosis), a few underwent esophagectomy
by a transmediastinal approach (laparotomy, no
thoracotomy, collar approach with hand-sewn anastomosis).
Reconstruction was routinely performed by a gastric
tube formation and pull-up, continuity was established
only in individual cases by a colonic interposition. We
routinely performed two-field lymphadenectomy in
patients with a thoraco-abdominal approach. In patients
with a transmediastinal approach, lymphadenectomy was
limited to the lower mediastinum and abdominal
compartment. The majority of patients received an
intraoperatively placed jejunostomy catheter for postoperative
Neither the anesthetic approach, nor postoperative care
processes were strictly standardized at our institution.
Whenever possible, patients received an epidural
catheter for intra-and postoperative pain management.
Patients were kept on a surgical intermediate care unit
for at least 4 days after surgery. Patients were restricted
to oral fluids until postoperative day (POD) 5 and
started on solids after a routine contrast esophagogram
ruled out anastomotic leak or stenosis. Patients usually
received 1ml/kg/h of Normofundin ® G-5 solution [Braun,
Melsungen, Germany] on the day of operation after
admission to the intensive care unit. Enteral feeding via
jejunostomy catheter was started 6 h after surgery and
was continued till patients were able to consume sufficient
solid food. Patients without a jejunostomy catheter
received total parenteral nutrition instead. In the operating
room and on the intermediate care unit, all patients were
monitored according to standard parameters regarding
blood pressure (systolic pressure goal >90 mmHg), and
urine output (targeting 0.3–0.5 ml/kg/h). Noradrenalin
was the standard catecholamine used intra- and
postoperatively in almost all cases.
Blood product transfusions were generally initiated
when hemoglobin levels were less than 8 g/dl in patients
without coronary artery disease or less than 10 g/dl in
patients with coronary artery disease. The crystalloid
fluid used was a balanced electrolyte solution (either
Jonosteril® [Fresenius Kabi, Bad Homburg Germany] or
Normofundin® G-5 [Braun, Melsungen, Germany]). The
colloidal solutions were based on hydroxyethyl starch
(HES) 6% (either Voluven® or Volultye® [Fresenius Kabi,
Bad Homburg, Germany]) with less sodium and chloride
and an acetate buffer.
Assessment of perioperative fluid management and
Intraoperative fluid administration was extracted from
the anesthetic protocols, the postoperative amount of
administered fluid from the electronic health records of
each patient. The type and amount of fluids given during
and after esophagectomy was evaluated. In further detail,
the amount and type of fluids administered during the
operation was assessed as well as the sum (of each type)
of fluids given on the operation day and until the end of
POD 4. Thus, not only the specific amount of fluids
given during the operation, but also the fluids given
postoperatively on the intensive care unit are displayed
and evaluated. Not considered were perspiratio
insensibilis and additional fluid loss not recorded in the charts.
Perioperative blood transfusion was defined as any
number of erythrocyte concentrates administered
intraoperatively or until POD 4.
Furthermore, the correlation of the intra- and
postoperative fluid administration and surgical outcome was
investigated. Postoperative complications were noted
and graded according to the Clavien-Dindo classification
. Primary endpoint of our study was adverse surgical
outcome, which was defined as at least one
postoperative complication graded Clavien-Dindo 3 or higher, thus
requiring any endoscopic, surgical or radiological
intervention. Complications contributing to this endpoint
were anastomotic leak, delayed gastric emptying,
intraabdominal abscess, hemorrhage, wound infection,
cardiac and respiratory complications. After discharge from
hospital, patients were followed up at the surgical
outpatient department and referred back either to the
department of medical oncology or to a resident
oncologist for adjuvant therapy (when indicated) and further
follow-up. Complications were recorded up to 3 months
The results of our study were gained by retrospective
analysis of our prospectively maintained
esophagogastric database. IBM SPSS Statistics for Windows,
(Version 21.0 Armonk, NY USA: IBM Corp.) was used for
statistical analysis. Categorical variables were put in
absolute and relative frequencies; differences were
evaluated by one-tailed Fisher’s exact test. Quantitative
values were expressed as medians with range, and
differences were measured using the Mann-Whitney-U-test or
Kruskal-Wallis-test as appropriate. Multivariate logistic
regression analysis with forward stepwise including was
used to identify independent risk factors for adverse
surgical outcome. Because overlapping variables (Fluid balance
on POD 0 and POD 4) were used in our analyses,
multivariate analysis was performed in different models with
the inclusion of only one of these variables each time to
prevent multicollinearity. Inclusion p for multivariate
analysis was 0.10. A p-value <0.05 was considered
Patients demographics & tumor and treatment
Between 1996 and 2014, 335 patients underwent
esophagectomy at our institution for esophageal cancer.
Eightyseven percent of the patients were male and the mean
age was 62 years. The majority of tumors were
adenocarcinomas (59%) and located in the lower third of the
esophagus (75%). Neoadjuvant chemoradiation was
performed prior to the operation in the majority of cases
(56%), while 22% received neoadjuvant chemotherapy
and 22% unimodal surgical treatment (Table 1).
Ninety-two percent of the patients were operated by a
thoraco-abdominal approach, the remaining 8% underwent
esophagectomy by a transmediastinal approach. The
anastomosis was located cervical in 45% and intrathoracic in
55% of the cases. In 96% reconstruction was performed by
a gastric tube pull-up, and in the remaining 4% continuity
was established by colon interposition. Median operating
time was 420 min and median hospital stay 22 days.
Tumors were postoperatively staged according to the
UICC-classification as Stage 0/I in 33% (including
complete remission), Stage II in 42%, Stage III in 19%
and Stage IV in 6%. Nineteen patients (6%) had a
margin-positive resection (Table 1).
Intra- and postoperative fluid balance
The intra- and postoperative fluid management is
displayed in Table 2.
From our data, we calculated a total median fluid
overload of 6000 ml (range 600 – 24300 ml) at the end
of the operation day (POD 0) and 5500 ml (range 4000
– 37200 ml) at the end of POD 4. The actual fluid
balance has to be estimated lower considering the
additional fluid loss like perspiratio insensibilis, which
would be very hard to quantify. Data regarding fluid
input and output were not available for 2 patients
intraoperatively, one additional patient on the operation day
and for another three additional patients for POD 1 – 4.
Patients were divided into groups according to their
fluid balance on POD 0 and again on POD 4: Fluid
balance above the median was defined as fluid overload,
below median as fluid restrictive. The majority of
patients (77%) were identical in the fluid groups on POD
0 and POD 4, but 11% with intraoperative fluid overload
were below average on POD 4, while 12% with
restrictive fluid management during the operation
showed an above-average fluid balance on POD 4.
Figure 1 displays the median IOF rate and total fluid
balance on POD 1 and 4.
Table 1 Demographics. tumor and treatment characteristics
Lower third/junctional tumor
Tumor histological type
Squamous cell carcinoma
Median operating time (min)
Median ICU stay (days)
Median Hospital stay (days)
n = 335
24.5 [14.6 – 45.9]
420 [203 - 906]
Displayed are demographic, tumour and treatment characteristics of 335
patients undergoing esophaegctomy
Erythrocyte concentrates were administered
intraoperatively in 36% of the cases (n = 122) with a median
amount of 900 ml (range 300 – 16200 ml), while fresh
frozen plasma was given in only 12% of the cases (n = 40,
median amount 700 ml, Range 200 – 11200 ml).
Until POD 4, 203 patients received erythrocyte
concentrates (61%), administered was a median of 900 ml
(range 300 – 16200 ml). Two hundred four patients
received at least one unit of fresh frozen plasma (61%,
median 1200 ml, range 200 – 9000). Sixty-seven percent
of all patients required catecholamine therapy during
the operation and directly after, while only 52% needed
further catecholamine therapy in the postoperative
phase. During the first four postoperative days, 61% of
the patients received diuretics.
Patients operated before 2006 received significantly
more intraoperative fluids (16 ml/kg/h versus 11 ml/kg/
h 2006 and after, p < 0.001) resulting in a more distinct
volume overload (8000 ml versus 5000 ml on POD and
8838 ml versus 3100 ml on POD 4, p < 0.001).
Perioperative outcome and association with fluid balance
Seventy-five percent of our patients developed at least
one postoperative complication according to the
Clavien-Dindo-Classification . Twenty-two percent
were managed conservatively (Grade II), while 44% of
the patients required further intervention or operation
(Grade III/IV). The in-hospital mortality was 8% (Grade
V). Most complications were either of pulmonary (in
53%) or surgical origin (in 47%). Twenty five percent of
the patients developed a medical complication, mostly
cardiac incidents (20%) or renal failure (15%). Table 3
shows the frequency and severity of postoperative
complications and the association with fluid overload on
POD 0 and 4. It is of note, that a fluid balance above
average on the operation day was strongly associated
with a higher rate of postoperative mortality (13 % vs
3%, p < 0.001) and complications (83% vs 66%, p =
0.001), especially severe complications (Grade III or
higher). Higher rates of pneumonia, pleural effusion,
need for tracheostomy, anastomotic leakage, and even
cardiac incidents were observed. Interestingly,
pulmonary embolism was the only complication registered
almost exclusively in the group with restricted fluid
balance (8 cases vs 1 case, p = 0.018).
Statistical analysis showed an even more distinct
correlation for the above-average fluid balance on POD
4, with significant values even for the rate of
reintubations (p < 0.001), wound infection (p = 0.007) and renal
complications (p = 0.01). Not surprisingly, neither fluid
balance on POD 0 nor POD 4 had any influence on the
rates of postoperative pneumo- and chylothorax, pleural
empyema, anastomotic stricture, postoperative ileus and
deep vein thrombosis.
The total fluid balance on POD 0 and 4 correlated
significantly with the severity of postoperative
complications: Patients with no complication had a median fluid
Table 2 Intra- and perioperative fluid balance
The table shows the intraoperative and postoperative fluid intake (intravenous fluids, transfusions, nutrion) and output (blood loss, drains, urin) on POD 0-4
including and the total balance resulting on POD 0 and 4
Fig. 1 Box-Whisker-Plot displaying the introperative and postoperative fluid balance. The median intraoperative fluid intake was 13 ml/kg/h (a),
the fluid balance added up to a median of 6000 ml on POD 0 (b) and a median of 5500 ml POD 4 (c). 76.9% of patients were identical in the
groups on POD 0 and POD 4
Severity of complicationsb
n = 333
n = 164
n = 165
Table 3 Association of intra- and postoperative fluid management with postoperative morbidity
n = 166
n = 166
aFisher’s exact test bComplications were graded according to Clavien/Dindo
Patients were divided by their total fluid balance (median cut) on POD 0 and POD 4. The table compares the postoperative morbidity and mortality rate in the
groups and the occurrence of specific complications
balance of 5300 ml on POD 0 and 3900 ml on POD 4,
while patients with a complication Grade II-IV had a fluid
overload of 6100 ml on POD 0 and 6000 ml on POD 4.
Patients who died subsequent to the operation had
received even higher amounts with 8000 ml on POD 0
and 10000 ml on POD 4 (p < 0.001). Figure 2 shows the
correlation between the severity of postoperative
complications and the fluid balance on POD 0 and 4.
Risk factor analysis for adverse surgical outcome
Patients with a complication grade III or higher were
defined as having an adverse surgical outcome (52%)
and underwent further risk factor analysis for adverse
surgical outcome. Univariate analysis (Table 4) identified
ASA-score (p = 0.002), recent smoking (p = 0.036),
reconstruction by colonic interposition (p = 0.036),
cervical anastomosis (p = 0.017) and perioperative blood
transfusion (p = 0.038) as risk factors. Sex, age, BMI,
alcohol abuse, type of multimodal therapy, surgical
approach, tumour localisation, histological type and
stage were not associated with adverse surgical outcome.
Most importantly, both, total fluid balance on the
operation day as well as on POD 4 were strongly associated
with adverse surgical outcome (p = 0.001), while the sole
rate of intraoperative fluid administration could not be
identified as a risk factor (p = 0.479).
Multivariate analysis (Table 5) confirmed only
ASAscore (p = 0.001) and fluid balance on POD 0 (p = 0.001)
as independent predictors of adverse surgical outcome.
Fluid balance on POD 4 was analysed in a separate
model to prevent multicollinearity and was likewise
confirmed as an independent risk factor(p = 0.001).
We noticed a shift of fluid management towards a
more restrictive regime over time. To analyse the
correlation between year of treatment and postoperative
morbidity, patients were divided by treatment period in two
groups (1996–2005 and 2006–14). Patients treated after
2006 had a significantly lower postoperative morbidity
(46% vs 53%, p = 0.015). In multivariate analysis
treatment period was eliminated (p = 0.741). Therefore the
effect has to be attributed to the changes made in
perioperative management and surgical technique.
Our single-center retrospective study analyses 335
patients undergoing esophagectomy for esophageal
Fig. 2 Box-Whisker-Plot displaying the correlation between the median fluid balance on POD 0 (a) and POD 4 (b) and the severity of
postoperative complications. Complications were graded according to Clavien/Dindo. The median fluid balance was significantly higher in
patients with postoperative complications on POD 0 as well as on POD 4
cancer represents and is the largest cohort study ever on
intra- and postoperative fluid management and its
impact on perioperative outcome of esophagectomy.
Postoperative morbidity was high with over 50% of
patients developing a relevant complication and with 8%
in-hospital mortality. However, these results are
consistent with perioperative outcome described in the recent
literature [13–15]. Our data suggest that intra- and
postoperative fluid restriction is associated with an improved
perioperative outcome, matching the results of several
investigations from the field of pancreatic and colorectal
Few observations also suggest restrictive fluid
management for patients undergoing esophagectomy [4, 16, 17].
To date, this recommendation is based on very limited
evidence. Early case series applying restrictive fluid
management to patients undergoing esophagectomy show
favourable results regarding postoperative morbidity, but
none of these studies was randomized [16, 17].
Retrospective analysis in small cohorts of patients were able
to show a correlation between intraoperative fluid
overload and adverse surgical outcome in patients after
esophagectomy [6, 18] and especially an association
between fluid overload and pulmonary morbidity after
Ivor-Lewis-esophagectomy . One very small
randomized controlled trial with 22 patients failed to establish
this correlation. Improved pulmonary function was
demonstrated after restrictive fluid management, but no
effect on postoperative complications .
Even though restrictive fluid management nowadays is
considered beneficial by most surgeons, it remains hard
to achieve. Our study shows a decrease of intra- and
postoperative fluid overload over time. Strategies used to
optimize postoperative fluid balance are the restriction
of intravenous fluids, the selective use of catecholamin
therapy and the generous application of diurectics
starting as early as possible. Another possibility to direct
fluid management are goal-directed strategies.
Goaldirected and “restrictive” intraoperative fluid
management strategies have been established in different
surgical specialties (pancreatic and colorectal) and are
supported by sufficient evidence provided by
randomized trials and systemic reviews . These strategies have
also been transferred to esophageal surgery, although
supporting data for this specific field are scarce .
Our results show that the sole quantification of fluid
input is not associated with impaired outcome, but that
total fluid balance is. These results would support
goaldirected therapy as a guideline for fluid management.
The pathophysiology of our findings may mainly be
related to fluid impact on perioperative lung physiology.
The postoperative morbidity of esophagectomy strongly
consists of the pulmonary component . Restrictive
fluid administration has proven to prevent acute lung
injury in patients after lung resection , a mechanism
that might be transferred to esophagectomy. In our
cohort, pulmonary complications occurred significantly
more often in patients with intraoperative (58% vs 48%)
or postoperative fluid overload (60% vs 45%).
Impaired wound healing may also contribute to
morbidity and mortality after esophagectomy. In
experimental settings, intraoperative fluid overload
impairs gastrointestinal wound healing [21–24],
another mechanism that might explain improved
outcome related to restrictive fluid management in our
study: Intraoperative and postoperative fluid overload
were associated with a threefold incidence of
anastomotic leakage in our analysis.
Table 4 Univariate analysis of predictors for adverse surgical outcome
Sex (n, %)
ASA score (n, %)
1 – 2 193
3 – 4 142
<25 kg/m2 179
≥25 kg/m2 154
Recent Smoking (n, %)
Multimodal therapy (n, %)
Neoadjuvant radiochemotherapy 189
Perioperative chemotherapy 73
Surgical approach (n, %)
Reconstruction (n, %)
Gastric tube 321
Colon interposition 14
Anastomosis (n, %)
Tumor histological type (n, %)
Squamous cell carcinoma 137
UICC-Stage (n, %)
1 – 2 251
3 – 4 84
1996 – 2005 159
2006 – 2014 176
Perioperative blood transfusion
Intraoperative fluid rate
<13 ml/kg/h 166
≥13 ml/kg/h 167
Table 4 Univariate analysis of predictors for adverse surgical outcome (Continued)
Fluid balance POD 0
Fluid balance POD 4
aAt least one Complication grade 3 or higher graded according to Clavien/Dindo, bFisher's exact test
We performed a risk factors analysis for the occurrence of adverse surgical outcome (defined as at least one complication graded 3 or higher). Displayed are the
analysed risk factors and their impact on the outcome
Our study analyses fluid administration over 4
postoperative days and correlates the results with
perioperative outcome. Most other previous studies
focused on intraoperative fluid administration.
Postoperative fluid management even has been analyzed over
the course of 2 days by only one study . Our
results show that fluid overload in the postoperative
phase is equal to intraoperative fluid overload as a
risk factor for postoperative morbidity. It can be
assumed that complications like pneumonia and
anastomotic leakage will contribute additionally to fluid
overload due to impaired cardiac circulation and
capillary leak syndrome. Put into perspective, since
these complications usually manifest clinically after
POD 4 , and certainly not intraoperatively, we
believe that this factor is largely negligible.
The retrospective design of our study certainly
allows only limited conclusions. Confounding factors
leading to intra- and postoperative fluid overload and
increased morbidity and mortality can only be
partially eliminated by multivariate analysis. Possibly this
Multimodal therapy (RCTX/CTX)
Reconstruction (Colon/gastric tube)
Perioperative blood transfusion (Y/N)
Treatment period (1996-2005/2006-14)
ASA score (3-4/1-2)
Fluid balance POD 0 (≥/< 6000 ml)
Fluid balance POD 4 (≥/< 5500 ml)
aAt least one Complication grade 3 or higher graded according
bMultivariate logistic regression analysis with forward stepwise including, Odds
ratio (OR), 95% confidence interval (CI)
The table shows the multivariate analysis of the risk factors identified by the
univariate analysis. Fluid balance on POD 0 and POD 4 were analysed in
separate models to prevent multicollinearity
study overvalues the negative effect of intra- and
postoperative fluid overload on the postoperative
morbidity. Our analysis shows that intraoperative
infusion have been reduced during the study period
and that a restrictive fluid management has already
been implemented in our hospital and is likely to be
an essential contributor to the reduced postoperative
morbidity after esophagectomy [1, 2]. On the other
hand improvement of surgical techniques and
perioperative management over time is another
confounder than cannot be eliminated by this analysis.
A further limitation of our study is its non-randomized
character. Patients were not randomized to restrictive or
liberal fluid management, but the decision was made to
some extent arbitrarily by the attending anesthesiologist
and surgeon. Operating time and intraoperative blood loss
might effect both postoperative fluid balanace and
morbidity. Blood transfusions were given in 61% of the
cases intra- or postoperatively and contributed to the
observed fluid overload. Perioperative blood transfusion
itself has been identified as a risk factor for adverse
surgical outcome in other analyses [26, 27]. The negative
effects of transfusion like immunosuppressive effects
mingle with the effects of volume overload and are difficult to
distinguish in our analysis. Multivariate analysis
eliminates perioperative blood transfusion as a risk factor
in our analysis in favor of volume overload. We
believe, that volume overload has to be considered as
a confounding factor in future analyses regarding
intra- and postoperative blood transfusion.
Our study identifies postoperative fluid overload
alongside high ASA-score as the strongest risk factor for
adverse surgical outcome after esophagectomy for
esophageal cancer. In the context of previous studies
from different surgical specialties our results suggest
that a restrictive fluid management can contribute to a
further reduction of postoperative complications after
There study was exclusively funded by the Department of Surgery, University
Medical Center Freiburg. There was no external funding source.
Availability of data and materials
The datasets analysed during the current study are available from the
corresponding author on reasonable request.
TG and JH were responsible for conception and design of the study and
drafted the Manuscript. BK, SB and GM were responsible for collection of
clinical data and assisted with analyses and interpretation. FM and TG
performed statistical analysis and helped to draft the manuscript. GM and
FM revised the article. All Authors have approved the manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The Medical Ethics Committee of the University of Freiburg approved the study.
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