Response to the letter to the editor: Hyperglycemia or inappropriate fluid therapy

We thank Dr. Tez for his comments on our recent publication entitled “Postoperative hyperglycemia affects survival after gastrectomy for cancer: A single-center analysis using propensity score matching.”1 His Letter to the Editor raises an interesting and debated topic in abdominal surgery, namely the perioperative management of fluid and electrolytes. In this regard, multiple recent studies underlined the benefits of a restricted, intraoperative and postoperative strategy of fluid management. More specifically, these studies showed a decrease in postoperative mortality as well as the rates of gastrointestinal, cardiac, and pulmonary complications when a restricted fluid regimen is employed.2 Despite these premises, our study was conducted during a time period when the restricted fluid regimen was not routine practice. This explains the “liberal” fluid regimen we used during the study period. Its principle was based on the idea that adequate fluid support is mandatory after long duration, open abdominal operations. To verify the adequateness of the fluid volumes, several parameters were monitored, namely urine output, blood pressure, heart rate, and the daily output from nasogastric tube and surgical drains; adjustments of fluid therapy were made on the basis of these parameters as needed. Based on the evidence reported in the literature, however, we more recently changed our policy of fluid management. More specifically, the intraoperative infusion of fluid monitoring is based currently on the principles of goal-directed, hemodynamic therapy.3 Additionally, we also changed our postoperative fluid management in favor of a restricted fluid infusion. Moreover, we are applying the principles of the Enhanced Recovery After Surgery protocol4 to the majority of patients, with a consequent early oral feeding beginning the first day postoperatively.