Goal-Directed Fluid Therapy Enhances Gastrointestinal Recovery after Laparoscopic Surgery: A Systematic Review and Meta-Analysis

Abstract

(1) Background: Whether goal-directed fluid therapy (GDFT) provides any outcome benefit as compared to non-goal-directed fluid therapy (N-GDFT) in elective abdominal laparoscopic surgery has not been determined yet. (2) Methods: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, Web of Science, and Scopus. The main outcomes were length of hospital stay (LOHS), time to first flatus and stool, intraoperative fluid and vasopressor requirements, serum lactate levels, and urinary output. Pooled risks ratios (RRs) with 95% confidence intervals (CI) were calculated for dichotomous outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. (3) Results: Eleven studies were included in the quantitative, and fifteen in the qualitative synthesis. LOHS (WMD: -1.18 days, 95% CI: -1.84 to -0.53) and time to first stool (WMD: -9.8 h; CI -12.7 to -7.0) were significantly shorter in the GDFT group. GDFT resulted in significantly less intraoperative fluid administration (WMD: -441 mL, 95% CI: -790 to -92) and lower lactate levels at the end of the operation: WMD: -0.25 mmol L^-1; 95% CI: -0.36 to -0.14. (4) Conclusions: GDFT resulted in enhanced recovery of the gastrointestinal function and shorter LOHS as compared to N-GDFT.

Keywords: enhanced recovery after surgery; goal-directed fluid therapy; haemodynamic monitoring; intraoperative fluid management; laparoscopic abdominal surgery; perioperative care.

Figure 1

PRISMA flowchart of selection.

Figure 2

Length of hospital stay (days). Length of hospital stay was significantly shorter in patients who received GDFT (WMD = −1.18 days; 95% CI = −1.84 days to −0.53 days) and also in the non-ERAS subgroup (WMD = −1.28 days; 95% CI = −2.12 days to −0.44 days). However, in the ERAS subgroup, our result was not significant (WMD = −1.18 days; 95% CI = −2.79 days to 0.43 days). Heterogeneity was high both in overall and in the non-ERAS group (I-squared = 80.1%; p < 0.01 and I-squared = 85.5%; p < 0.01), and moderate in the ERAS subgroup (I-squared = 64.4%; p = 0.06).

Figure 3

Time to first stool and time to first flatus. Time to first stool (A) was significantly reduced in patients receiving GDFT compared to the controls (WMD = −9.81 h; 95%; CI = −12.66 h to −6.97 h). No evidence was found for heterogeneity (I-squared = 0.0%; p = 0.85). Time to first flatus (B) was significantly shortened in the GDFT group compared to the controls (WMD = −5.63 h; 95% CI = −10.87 h to 0.38 h). High heterogeneity was detected (I-squared = 92.0%; p < 0.01). WMD: weighted mean difference, SD: standard deviation, GDFT: goal-directed fluid therapy, N-GDFT: non-goal-directed fluid therapy, CI: confidence interval. p < 0.1 was considered significant.

Figure 4

Clinical outcomes at the end of operation. Intraoperative fluid requirement (A) was significantly lower (WMD = −440.84 mL; 95% CI: −789.73 mL to −91.96 mL) in the GDFT group. High heterogeneity was detected (I-squared = 96.9%, p < 0.01). There was no significant difference in the number of patients requiring vasopressors intraoperatively (B) between the goal- and the non-goal-directed groups. (RR = 0.90; 95% CI = 0.71 to 1.14). Low heterogeneity was found (I-squared = 44.0%; p < 0.01). There was no significant difference in intraoperative urinary output standardised for length of surgery (C) between the two groups (SMD = 5.69 mL h⁻¹; 95% CI = −2.16 mL h⁻¹ to 13.54 mL h⁻¹). Data were not considered heterogeneous (I-squared = 0.0%; p = 0.96). Serum lactate levels (D) were significantly lower in the GDFT group compared to N-GDFT (WMD = −0.25 mmol L⁻¹; 95% CI −0.36 mmol/ to −0.14 mmol L⁻¹). There is no evidence for heterogeneity (I-squared = 42.7%; p = 0.18). WMD: weighted mean difference, SMD: standardised mean difference, RR: risk ratio, SD: standard deviation. GDFT: goal-directed fluid therapy, N-GDFT: non-goal-directed fluid therapy, CI: confidence interval. p < 0.1 was considered significant.