ABSTRACT
Background
Reliable data on optimal fluid management in the perioperative period for patients with advanced ovarian cancer undergoing cytoreductive surgery is limited. These patients often present with malignant ascites and are prone to significant fluid shifts perioperatively. For this reason, our objective was to define clinical targets for optimal fluid balance and determine whether initial ascites should be included in fluid‐loss calculations by examining the association between perioperative fluid balance and major postoperative complications.
Methods
This prospective, observational study conducted in a centralized and public healthcare system setting in Sweden between 2020 and 2023 included patients with advanced ovarian cancer, > 18 years of age, scheduled for upfront cytoreductive surgery, an ASA physical status I–III with no speech/language issues. The primary outcome was major postoperative complication within 30 days of surgery. The measurements of fluid input and output, cut‐offs for fluid balance, perioperative time, and postoperative complications were defined a priori. The association between fluid balance and major postoperative complications was assessed by multivariable regression, adjusted for predefined covariates, yielding odds ratios (OR) with 95% confidence intervals (CI).
Results
Of 175 enrolled patients, 162 were included in the final analysis. In the adjusted analysis, there was a significant association between fluid balance of 1750–2700 mL, OR 3.40 (95% CI 1.06–10.9; p = 0.04) and > 2700 mL, OR 3.91 (95% CI 1.33–11.5; p = 0.01) and major postoperative complications. When including initial ascites as fluid loss, a balance of > 2700 mL was associated with major postoperative complications, OR 2.59 (95% CI 1.01–6.66, p = 0.047).
Conclusion
An optimal target for perioperative fluid balance to decrease the odds of major postoperative complications is suggested to be < 1750 mL. If initial ascites is included as loss in the calculation of balance, the optimal target of fluid balance is suggested to be < 2700 mL. These results provide practical clinical reference values that may assist anesthesiologists and surgical teams in optimizing perioperative fluid management in advanced ovarian cancer.
Editorial Comment
This secondary analysis of a trial ovarian cancer operative cohort assessed the relation of the estimated fluid balance over the operative day 24 h to major postoperative complications. The findings showed that the groups where the fluid balance was in the categories higher and also most positive had higher odds for having a major complication compared to the group with lowest fluid balance. Ascities fluid was an issue in this cohort, which was managed in the analysis.
Trial Registration: ClinicalTrials.gov: NCT04065009
1. Introduction
Fluid management is a cornerstone of perioperative care and plays a pivotal role in ensuring optimal outcome during and after surgery. Maintaining a proper fluid balance is crucial for cardiovascular stability, adequate tissue perfusion, and the prevention of complications, both per‐ and postoperatively [1, 2]. During extensive and high complexity surgery, such as cytoreductive surgery for advanced ovarian cancer, fluid management is particularly important [3]. Moreover, as cytoreductive surgery and adjuvant chemotherapy combined constitute primary treatment, facilitating the timely initiation of adjuvant chemotherapy by minimizing the risk of postoperative complications is imperative [4, 5].
Patients with advanced ovarian cancer often present with malignant ascites, which makes them more susceptible to hemodynamic instability during surgery [6]. In combination with extensive resections of the peritoneum, which under normal circumstances reabsorbs peritoneal fluid, and a long duration of surgery with an exposed peritoneal surface, massive fluid shifts may occur.
Approximately 20% of patients undergoing cytoreductive surgery for advanced ovarian cancer experience major postoperative complications [5, 7]. Reducing this risk is essential, as delays or omission of subsequent adjuvant chemotherapy due to complications may lead to poorer oncologic outcome [8, 9]. Consequently, optimizing perioperative care to reduce the risk of postoperative complications is important. Nevertheless, in the majority of studies investigating the effect of perioperative fluid balance during and after abdominal surgical procedures, patients with advanced ovarian cancer are scarcely represented [10]. Moreover, what the assessment of fluid balance comprises, and the definition of perioperative duration is ill‐defined [11, 12]. In addition, the reported observations have been retrospective without a priori definitions of fluid balance and perioperative time [13, 14]. Consequently, the optimal perioperative fluid management in advanced ovarian cancer has not been established. Neither if malignant ascites measured at the beginning of the surgical procedure should be counted as fluid loss or disregarded in the assessment of fluid balance.
For these reasons, our objective was to prospectively investigate the association between perioperative fluid balance, with pre‐defined cut‐offs and measurements, and major postoperative complications to define tangible and clinically meaningful targets for optimal fluid balance. Moreover, to assess whether initial ascites should be included in the measurement of fluid balance.
2. Methods
This was a prospective observational and descriptive study conducted in two tertiary referral centers, Skåne University Hospital, Lund, and Karolinska University Hospital, Stockholm, Sweden, in a centralized and public health care system. All participating patients provided written informed consent, and the study was approved by the Swedish Ethical Review Authority (Dnr: 2019‐05149).
All data used in this study was prospectively collected in the electronic study database of the Intra Peritoneal Local Anesthetics in advanced Ovarian Cancer (IPLA‐OVCA) phase III trial with accrual during August 2020 through December 2023 (ClinicalTrials.gov nr: NCT04065009, European Union Clinical Trials Register nr: 2019‐003299‐38/SE) [15]. IPLA‐OVCA was a randomized, double‐blind, placebo‐controlled trial to investigate the effect of intraperitoneal administration of local anesthetics on postoperative recovery, measured by the time interval to adjuvant chemotherapy [15]. While participants were initially randomized to treatment groups in the original trial, the present analysis focuses on fluid management across all participants, regardless of initial treatment assignment. This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [16].
2.1. Participants/Cohort
Included patients were scheduled for upfront cytoreductive surgery with curative intent for International Federation of Gynecology and Obstetrics (FIGO) stages III and IV ovarian cancer, had an age ≥ 18 years, and an American Society of Anesthesiologist physical status classification (ASA) of I–III. Exclusion criteria included allergy to any component drug (Ropivacaine or Sufentanil) or a contraindication to epidural anesthesia.
Patients with cognitive, speech, or language difficulties were also excluded, as well as those in whom cytoreductive surgery was not attempted due to extensive tumor dissemination or who received another histopathologic diagnosis after surgery. Patients with missing data on fluid balance variables were excluded from the analyses. Standard care included bowel preparation, thoracic epidural, arterial line, vasopressor to counteract possible vasodilation of epidural, invasive hemodynamic monitoring (connected to the arterial line), first postoperative night at a high‐dependence postoperative unit, early oral intake, and low‐molecular heparin from the evening before the date of surgery.
2.2. Explanatory Variable
(1a) Fluid balance, defined as the difference between fluid input and fluid losses from the arrival at the operating theatre (t = 0) until 06:00 the morning after surgery (t = 1); all cases were scheduled to start as first case in the morning at the same time.
Fluid balance was categorized into three different predefined groups, either as < 1750 mL (negative fluid balance was included in this group), 1750–2700 mL, or > 2700 mL based on a previous meta‐analysis [11].
Fluid input was defined as: crystalloid, colloid, packed blood products, intravenous drugs, and oral intake. After 06:00 postoperative day 1, oral intake was encouraged; however, if there was need for IV fluids, this was managed at the discretion of the responsible physician. All measurements were performed according to clinical routine.
Fluid loss was defined as urine output, blood loss (suction and swab weighing), gastric retention, possible surgical drains, and ascites produced during surgery.
(1b) Modified fluid balance, defined as above. However, the initial amount of malignant ascites, if present, (measured immediately after incision) was included in the fluid losses. The initial amount of malignant ascites was collected immediately after incision of the peritoneum with a suction inserted in the abdomen until the abdomen was empty of visible ascites and then measured.
2.3. Outcome Variable
The primary outcome was major postoperative complications within 30 days after surgery according to the Clavien‐Dindo Classification (CDC), grade ≥ 3 (complication requiring intervention with or without anesthesia or life‐threatening complication requiring intensive care unit management or death) [7].
2.4. Co‐Variables
Co‐variables were predefined and chosen based on known clinical associations with the primary outcome and/or previous publications: age (years), Body Mass Index (BMI) (kg/m2), FIGO stage, ASA score, preoperative plasma albumin (g/L) and surgical complexity score (SCS) [17].
2.5. Statistical Analysis
Descriptive statistics were presented with numbers and proportions (n (%)), median and interquartile ranges (IQR) or mean ± standard deviation (SD) as appropriate. The effect of perioperative fluid balance with predefined cut‐offs, measured from the start of surgery until 06:00 the morning after surgery, along with other clinical variables, on CDC grade ≥ 3 was assessed using logistic regression. The five co‐variables were age (continuous), BMI (continuous), FIGO stage (III, IV), ASA score (I, II, III), preoperative plasma albumin (continuous), SCS (low (0–3), medium (4–7), high (≥ 8)). Results from the two regression models (fluid balance and modified fluid balance) were presented as OR (with 95% Confidence intervals (CI)). Reported p values refer to the Wald test and were two‐sided. The significance level was set to 5%. All statistical analysis was performed using the statistical software Stata version 18.
2.6. Prior Publication
Preliminary data were presented in Emma Hasselgren's PhD dissertation, and data from this paper were to be presented at the European Society of Gynecologic Oncology Congress, February 20–23, 2025, in Rome, Italy.
3. Results
A total of 175 patients were enrolled in the study; 13 patients were excluded due to missing information on either fluid input, fluid losses, or both, leaving 162 patients for final analysis; see Figure 1.
FIGURE 1.
Selection of women for analysis from the intra peritoneal local anesthetics in advanced ovarian cancer (IPLA OVCA) trial. The perioperative and clinical characteristics of the 13 patients excluded due to missing data on fluid balance are presented in Table S4.
The clinical characteristics are presented in Table 1. The median age was 66 (IQR 57–74) and most patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 (64.8%, n = 105), ASA score II (57.4%, n = 93) and FIGO stage III (81.5%, n = 132); see Table 1.
TABLE 1.
Clinical characteristics of analyzed patients with advanced ovarian cancer subjected to upfront cytoreductive surgery.
| Variable | Total cohort |
|---|---|
| n = 162 | |
| Age (years), median (IQR) | 66 (57–74) |
| BMI, median (IQR) | 25 (22–28) |
| Pre‐operative Charlson index score a , median (IQR) | 2 (1–3) |
| Pre‐operative ECOG performance status, no. (%) | |
| 0 | 105 (64.8) |
| 1 | 43 (26.5) |
| 2 | 12 (7.4) |
| Missing value | 2 (1.2) |
| Suspected FIGO stage before surgery, no. (%) | |
| III | (81.5) |
| IV | 30 (18.5) |
| ASA score, no. (%) | |
| I | 21 (13.0) |
| II | 93 (57.4) |
| III | 47 (29.0) |
| Missing value | 1 (0.6) |
| Smoking status, no. (%) | |
| No | 150 (92.6) |
| Yes | 12 (7.4) |
| Pre‐operative CA‐125 (kU/L), median (IQR) | 485 (167 to 1250) |
| Pre‐operative Albumin (g/L), median (IQR) | 35 (32 to 38) |
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; CA‐125, cancer‐associated antigen 125; ECOG, Eastern cooperative oncology group; FIGO, International federation of gynecology and obstetrics; IQR, interquartile range, presented as 1st and 3rd quartile.
Age‐adjusted Charlson index score; score for metastatic tumor not included.
The perioperative characteristics are presented in Table 2. The median operation time was 310 (IQR 211–390) minutes, and a high surgical complexity score was most prevalent (48.8%, n = 79). The mean volume of initial malignant ascites was 1044 (SD 1733) mL. Median perioperative fluid balance not including initial malignant ascites was 2715 (IQR 1830–3714) mL, and when including initial malignant ascites as fluid loss, it was 2116 (IQR 886–3139) mL; see Table 2.
TABLE 2.
Perioperative factors and fluid balance of analyzed patients who underwent cytoreductive surgery for advanced ovarian cancer.
| Variable | Total cohort |
|---|---|
| n = 162 | |
| Operation time (minutes), median (IQR) | 310 (211–390) |
| Surgical complexity score a , no. (%) | |
| Low 0‐3 | 25 (15.4) |
| Medium 4–7 | 58 (35.8) |
| High ≥ 8 | 79 (48.8) |
| Estimated blood loss b (mL), median (IQR) | 850 (480–1500) |
| Ascites present c (mL), no. (%) | |
| Yes | 139 (85.8) |
| No | 21 (13.0) |
| Ascites volume c (mL), mean (SD) | 1044 (1733) |
| Intra‐abdominal residual tumor (cm), no. (%) | |
| 0 | 103 (63.6) |
| 0.1–0.5 | 25 (15.4) |
| 0.6–1.0 | 13 (8.0) |
| > 1 | 21 (13.0) |
| Epidural d , no. (%) | |
| Yes | 158 (97.5) |
| No | 3 (1.9) |
| Invasive hemodynamic monitoring e , no. (%) | |
| Yes | 134 (82.7) |
| No | 21 (13.0) |
| Peri‐operative fluid balance f (mL), median (IQR) | 2715 (1830–3714) |
| Peri‐operative fluid balance f groups (mL), no. (%) | |
| < 1750 | 38 (23.5) |
| 1750–2700 | 45 (27.8) |
| > 2700 | 79 (48.8) |
| Peri‐operative modified fluid balance g (mL), median (IQR) | 2116 (886–3139) |
| Peri‐operative fluid balance g groups (mL), no. (%) | |
| < 1750 | 67 (41.4) |
| 1750–2700 | 41 (25.3) |
| > 2700 | 54 (33.3) |
| Total fluid given (mL), median (IQR) | 6425 (5350–6968) |
| Major postoperative complication h , no. (%) | 50 (30.9) |
| Length of stay (days), mean (SD) | 9 (6) |
Abbreviations: IQR, inter quartile range, presented as 1st and 3rd quartile; SD, standard deviation.
According to the Mayo clinic surgical complexity score.
Missing data: 1 patient.
Measured immediately after incision. Missing data: 2 patients.
Missing data: 1 patient.
Connected to the arterial line. Missing data: 4 patients.
Total fluid given from start of surgery until 06:00 the day after surgery minus total fluid losses from start of surgery until 06:00 the day after surgery.
Initital ascites at the start of surgery included in total fluid losses.
Defined as Clavien‐Dindo grade ≥ 3 within 30 days after surgery.
Additional details on surgical extent, procedures, and outcomes are specified in Table S1.
The uni‐ and multivariable analyses are presented in Figure 2. 31% (n = 50) of all patients experienced a major postoperative complication; the specific complication within the Clavien‐Dindo grade is presented in Table S2 and the specific complication within each fluid balance category is presented in Table S3.
FIGURE 2.
Forest plot of uni‐ and multivariable logistic regression of odds of major postoperative complications1 in patients with ovarian cancer, including fluid balance. ASA, American society of anesthesiologists; CI, confidence interval; FIGO, International federation of gynecology and obstetrics; OR, odds ratio. 1Defined as Clavien‐Dindo grade ≥ 3 within 30 days after surgery. 2Number of patients with major postoperative complications, defined as Clavien‐Dindo grade ≥ 3 within 30 days after surgery. 3Adjusted for: Age, suspected FIGO stage (IV, III), ASA score (I, II, III), preoperative plasma Albumin, surgical complexity score according to Mayo (low, medium, high). 4Walds test. #Total fluid given from start of surgery until 06:00 the day after surgery minus total fluid losses from start of surgery until 06:00 am the day after surgery. ##Initial ascites at start of surgery included in total fluid losses.
In the univariable analysis, there was a significant association between a fluid balance > 2700 mL and major postoperative complications, OR 3.09 (95% CI 1.16–8.28; p = 0.03), no association was evident in the modified fluid balance where the initial malignant ascites was included in the fluid losses.
In the adjusted analysis, both a fluid balance category 1750–2700 mL, OR 3.40 (95% CI 1.06–10.9; p = 0.04) and a fluid balance > 2700 mL, OR 3.91 (95% CI 1.33–11.5; p = 0.01) were associated with major postoperative complications. Moreover, a modified fluid balance (where initial malignant ascites was included in the fluid losses) of > 2700 mL was also associated with major postoperative complications, OR 2.59 (95% CI 1.01–6.66, p = 0.047).
4. Discussion
Our study indicates that a fluid balance > 1750 mL, representing the difference between fluid intake and losses (excluding initial malignant ascites), assessed within the first day of surgery, was associated with major postoperative complications in advanced ovarian cancer patients undergoing cytoreductive surgery. In addition, when including initial ascites to calculated fluid losses, an association was observed with a fluid balance > 2700 mL.
Fluid management is a significant variable to consider during surgery, and it has been suggested that 17% of postoperative complications may be attributed to inadequate fluid management [18]. However, defining fluid balance remains challenging, as comparisons across studies are complicated by heterogeneous patient populations and varying definitions of fluid balance [19]. Some studies advocate a net zero fluid balance, while others recommend a cautious approach to fluid restriction [20, 21]. For example, the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial investigated a restrictive intravenous fluid strategy targeting net zero fluid balance within 24 h postoperatively [21]. The trial found no improvement in overall health outcomes but observed an increased risk of acute kidney injury. Notably, 91% of participants in the RELIEF trial underwent non‐gynecological surgery, 36% had no underlying malignancy, and fluid management was based solely on fluid input rather than actual net balance. As a result, the findings are not readily comparable to those of the current study. In the 2019 Enhanced Recovery after Surgery (ERAS) gynecologic oncology recommendation, maintaining euvolemia is discussed, and goal‐directed fluid therapy (GDFT) is recommended. However, there is no clear recommendation regarding fluid balance targets and no numerical thresholds are specified [22]. This recommendation is mainly based on data from patients subjected to colorectal surgery that may not directly be generalized to advanced ovarian cancer [22]. In the latest ERAS gynecologic oncology recommendation update, there are no recommendations on the management of fluid balance [23]. At participating hospitals in the present study, there is an ERAS protocol available and most patients follow many, if not all, of the recommended parts of the protocol. In addition, there is a recommendation to use GDFT and 81.5% of included patients in the present study had invasive hemodynamic monitoring facilitating GDFT.
Perioperative fluid management in patients with advanced ovarian cancer is complex due to significant fluid changes occurring during and after surgery, influenced by low plasma albumin levels, the presence of ascites, and the possibility of postoperative fluid collections secondary to resection of large parts of the peritoneum [24]. There are very few previous studies focusing on fluid management during cytoreductive surgery in advanced ovarian cancer [13, 14]. Desale et al. [13] suggested an association between large positive fluid balance and surgical site infection, where weight gain was used as a surrogate measure of fluid status. In our previous study, we suggested an association between larger net fluid balance (> 3 L) and major postoperative complications after cytoreductive surgery for advanced ovarian cancer [14]. However, in this retrospective study, it became evident that retrospective data collection can be challenging, as estimates may be flawed or inaccurate without clear definitions of fluid balance (i.e., measurement of fluid input and losses), duration of the measurement, and if the initial ascites was included in fluid loss [11, 14, 25, 26]. Accordingly, and as there are no definitive guidelines on fluid management in advanced ovarian cancer, we designed and conducted the present study.
The duration of the assessment of perioperative fluid balance is often undefined, yet important, as a longer time also increases the risk of confounding by indication (i.e., is the complication due to fluid balance or is fluid management different because of a complication). Moreover, an accurate and prospective measurement is essential. For this reason, in the present study, we chose to define this time as the period from arrival in the operating theatre to 06:00 the following morning, aligning with the time of measurement in the clinical routine at the centers.
Varadhan et al. [11] investigated the effect of perioperative fluid therapy on postoperative complications after elective intraabdominal surgery in a meta‐analysis of randomized controlled trials; nine studies and 801 patients were included. Fluid balance was defined based on fluid input in three categories: < 1750 mL (restricted fluid therapy), 1750–2700 mL (balanced fluid therapy) and > 2700 mL (liberal fluid therapy). Patients in the balanced group had a decreased risk of postoperative complications RR, 0.59 (95% CI 0.44–0.81, p < 0.001) [11]. As individual reports on restrictive/liberal fluid therapy or fluid balance include heterogeneous populations, cut‐offs, and surgical procedures, we benchmarked our a priori definition of fluid balance categories in the present study against this large meta‐analysis [11, 14, 27]. However, we modified the calculation to include total fluid losses, creating a fluid balance calculation instead of only fluid input. This adjustment was made to account for significant fluid shifts often observed during cytoreductive surgery for advanced ovarian cancer.
Little attention has been directed to the clinical conundrum of whether the initial malignant ascites should be included in measurements of fluid‐balance. Although not clearly defined or supported by evidence, the general standard practice at both participating hospitals during the study period was to exclude the initial ascites volume from fluid loss calculations. Nevertheless, this decision was ultimately left to the discretion of the attending anesthesiologist and was not influenced by this observational study. A study addressing the implementation of an ERAS protocol during cytoreductive surgery for advanced ovarian cancer included ascites in the calculation of fluid balance however without replacing this fluid loss [28]. Similarly, yet a study investigating GDFT during surgery for gynecological malignancies accounted for ascites in the fluid losses [29]. However, it remains uncertain, in both these studies, whether the initial ascites, which can be substantial in volume, was factored into the fluid management calculations. In the present study, when including initial ascites in fluid losses, the association with major postoperative complications was evident however with a higher fluid balance cut‐off category (< 2700 mL). As the mean initial ascites volume was ~1000 mL, this corresponds with the lower cut‐off category (< 1750 mL) evident when excluding initial ascites in the fluid loss.
A phase III randomized controlled trial investigating perioperative fluid balance is not methodologically feasible, as clinical and ethical considerations preclude the random allocation of patients to different fluid balances. In the absence of such trials, the design of a robust comparative cohort study requires reliable baseline data, including typical perioperative fluid balance parameters, the distribution of fluid balance categories within the target population, and standardized definitions of the perioperative period and measurement protocols. The lack of these foundational data formed the principal rationale for conducting the present study. Given these constraints, an observational case‐series design was selected as the most appropriate and feasible approach. While this design inherently limits the ability to draw causal inferences, the study was strengthened by prospective data collection with a monitored database, an a priori definition of fluid balance categories, measurement protocols, prespecified primary outcome and covariates known to influence fluid status and finally separate analysis including or excluding initial malignant ascites. However, the observational nature of the study introduces potential for residual confounding, and the relatively small sample size reduces the precision. The inclusion of two study centers increases the generalizability of the finding; however, it may also introduce center‐related variability despite adherence to a shared clinical protocol. Behavioral bias may also have been introduced as the surgical and anesthesiology teams were aware of the study objectives. Nonetheless, no aspect of routine clinical care was altered for the purpose of this study.
Despite these limitations, this is the first study to prospectively examine perioperative fluid balance specifically in patients with advanced ovarian cancer and provides valuable descriptive data and a necessary framework for the development of future hypothesis‐driven, comparative investigations with formal power and sample size analysis.
In conclusion, our findings support the current consensus recommending against extreme fluid input or restriction, to rather aim for a net positive fluid balance in complex high‐risk surgeries [30]. The results suggest a tangible clinical target for perioperative fluid balance with an optimal cut‐off of < 1750 mL (excluding initial ascites) or < 2700 mL (including initial ascites) measured from incision to the morning after cytoreductive surgery in advanced ovarian cancer to reduce the odds of major postoperative complication.
Author Contributions
E.H. and S.S. contributed to study idea and design, prepared first draft of manuscript, tables and figures. E.H., N.K., H.F., H.B., D.Z., D.H., M.A., K.T., P.K. and S.S. contributed with data acquisition. H.J. performed the statistical analyses. All authors analyzed and interpreted the data, commented, edited, reviewed and finally approved the last version of the manuscript.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Specific procedures performed during cytoreductive surgery.
Table S2: Specific postoperative complications within the Clavien‐Dindo Grade.
Table S3: Specific postoperative complications within the fluid balance categories.
Table S4: Clinical and perioperative characteristics of patients with missing data on fluid balance.
Acknowledgments
We would like to thank the clinical research unit at the Department of Perioperative Medicine and Intensive Care at Karolinska University Hospital, Stockholm, Sweden; the Clinical Trials Office and the Centre for Clinical Cancer Research at Karolinska University Hospital, Stockholm, Sweden; moreover, all hospital staff at Karolinska University Hospital, Stockholm, and Skåne University Hospital, Lund, Sweden, who contributed to this study; finally, we would like to thank all patients with ovarian cancer treated at our institutions.
Hasselgren E., Kofoed N. G., Falconer H., et al., “Prospective Assessment of Clinically Relevant Fluid Balance Thresholds Associated With Postoperative Complications in Advanced Ovarian Cancer,” Acta Anaesthesiologica Scandinavica 69, no. 9 (2025): e70112, 10.1111/aas.70112.
Funding: This work was supported by Swedish Cancer Society (20 0245 P 03H and 23 0627 JCIA to S.S.), Region Stockholm County Council (20200004 and FoUI‐973310 to S.S.), the Cancer Research Funds of Radiumhemmet, Stockholm (194142 to S.S.), the Swedish Society of Medicine (SLS‐972109 to S.S.) and the European Society of Anesthesiology, Research Support Grant (ESAIC_GR_2020_EH to E.H.).
Data Availability Statement
Data will be shared upon reasonable request to the last author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Specific procedures performed during cytoreductive surgery.
Table S2: Specific postoperative complications within the Clavien‐Dindo Grade.
Table S3: Specific postoperative complications within the fluid balance categories.
Table S4: Clinical and perioperative characteristics of patients with missing data on fluid balance.
Data Availability Statement
Data will be shared upon reasonable request to the last author.