Goal-directed fluid therapy does not reduce postoperative ileus in gastrointestinal surgery: A meta-analysis of randomized controlled trials

Xiongxin Zhang, Wei Zheng, Chaoqin Chen, Xianhui Kang, Yueying Zheng, Fangping Bao, Shuyuan Gan, Shengmei Zhu, Xiongxin Zhang, Wei Zheng, Chaoqin Chen, Xianhui Kang, Yueying Zheng, Fangping Bao, Shuyuan Gan, Shengmei Zhu

Abstract

Background: Perioperative goal-directed fluid therapy (GDFT) aiming to maintain individual fluid balance based on sensitive parameters was prevalent in major surgery, especially in enhanced recovery after surgery (ERAS) pathway. This meta-analysis was conducted for the purpose of evaluating whether GDFT impacts on occurrence of postoperative ileus and whether its application is worthwhile in gastrointestinal surgery.

Methods: A systematic search of RCTs compared GDFT with other fluid management in patients undergoing gastrointestinal surgery from the PubMed, Web of Science, Embase, Cochrane Library databases was implemented. The primary outcome is incidence of postoperative ileus. Other outcome measures were length of hospital stay (LOS), postoperative morbidity and mortality. Subgroup analysis was planed a prior to verify the definite role of GDFT.

Results: 12 trials consisted of 1836 patients were included in the final analysis. GDFT did not influence the occurrence of postoperative ileus (relative risk, RR 0.71, 95% confidence interval, CI 0.47-1.07, P = .10), with moderate heterogeneity (I = 29%, P = .16). No difference was found between GDFT and control groups in LOS (mean difference -0.17 days, 95% CI -0.73 to 0.39, P = .55), total complication rate (RR 0.92, 95% CI 0.81-1.05, P = .23), and 30-day mortality (RR 0.91, 95% CI 0.47-1.75, P = .77). In other secondary outcomes, only wound infection rate was lower in the GDFT group (RR 0.68, 95% CI 0.50-0.93, P = .02). When performed subgroup analysis, GDFT was superior in reduction ileus only when compared with standard therapy or in those outside ERAS.

Conclusions: It is possible that GDFT dose not affect the occurrence of postoperative ileus in gastrointestinal surgery. It scarcely influences postoperative morbidity and mortality as well. However, lower incidence of ileus is observed in GDFT group either outside ERAS or compared with standard fluid therapy. Probably, GDFT may not be necessary in the ERAS pathway or if a hybrid approach is adopted.

Conflict of interest statement

The authors declare no conflicts of interest interests.

Figures

Figure 1
Figure 1
PRISMA diagram describing the identification of studies for the review.
Figure 2
Figure 2
Funnel plot for postoperative ileus. The scatter represents single studies. Log risk ratio (RR), natural logarithm of the RR; SE (log RR), standard error of the log RR.
Figure 3
Figure 3
Forest plots of subgroup analysis of comparing postoperative ileus between the GDFT group and the control group in gastrointestinal surgery (GDFT vs standard therapy or restrict therapy).
Figure 4
Figure 4
Forest plots of subgroup analysis of comparing postoperative ileus between the GDFT group and the control group in gastrointestinal surgery (GDFT was applied in ERAS pathway or non-ERAS pathway).

References

    1. Wolthuis AM, Bislenghi G, Fieuws S, et al. Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2016;18:1–9.
    1. Barletta JF, Senagore AJ. Reducing the burden of postoperative ileus: evaluating and implementing an evidence-based strategy. World J Surg 2014;38:1966–77.
    1. Vather R, O’Grady G, Bissett IP, et al. Postoperative ileus: mechanisms and future directions for research. Clin Exp Pharmacol Physiol 2014;41:358–70.
    1. Bragg D, El-Sharkawy AM, Psaltis E, et al. Postoperative ileus: recent developments in pathophysiology and management. Clin Nutr (Edinburgh, Scotland) 2015;34:367–76.
    1. Marjanovic G, Villain C, Juettner E, et al. Impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg 2009;249:181–5.
    1. Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to enhanced recovery after surgery (ERAS). Can J Anesth 2015;62:158–68.
    1. Gupta R, Gan TJ. Peri-operative fluid management to enhance recovery. Anesthesia 2016;71Suppl 1:40–5.
    1. Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials. Ann Surg 2016;263:465–76.
    1. Pearse R, Dawson D, Fawcett J, et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005;9:R687–693.
    1. Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anesthesia 2008;63:44–51.
    1. Noblett SE, Snowden CP, Shenton BK, et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Brit J Surg 2006;1069–76.
    1. Zakhaleva J, Tam J, Denoya PI, et al. The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis 2013;15:892–9.
    1. Zheng H, Guo H, Ye J-R, et al. Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. World J Surg 2013;37:2820–9.
    1. Gomez-Izquierdo JC, Feldman LS, Carli F, et al. Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery. Brit J Surg 2015;102:577–89.
    1. Giglio MT, Marucci M, Testini M, et al. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Brit J Anesth 2009;103:637–46.
    1. Gomez-Izquierdo JC, Trainito A, Mirzakandov D, et al. Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial. Anesthesiology 2017;127:136–49.
    1. Srinivasa S, Lemanu DP, Singh PP, et al. Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery. Brit J Surg 2013;100:1701–8.
    1. Cohn SM, Pearl RG, Acosta SM, et al. A prospective randomized pilot study of near-infrared spectroscopy-directed restricted fluid therapy versus standard fluid therapy in patients undergoing elective colorectal surgery. Am Surg 2010;76:1384–92.
    1. Jammer I, Ulvik A, Erichsen C, et al. Does central venous oxygen saturation-directed fluid therapy affect postoperative morbidity after colorectal surgery? A randomized assessor-blinded controlled trial. Anesthesiology 2010;113:1072–80.
    1. Brandstrup B, Svendsen PE, Rasmussen M, et al. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: Near-maximal stroke volume or zero fluid balance? Brit J Anaesth 2012;109:191–9.
    1. Pestaña D, Espinosa E, Eden A, et al. Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth Analg 2014;119:579–87.
    1. Phan TD, D'Souza B, Rattray MJ, et al. A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an enhanced recovery after surgery program. Anesth Intensive Care 2014;42:752–60.
    1. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005;5:13.
    1. Higgins J, Green S. Cochrane handbook for systematic reviews of interventions Version 5.1.0. [updated March 2011]. The Cochrane Collaboration, 2011. .
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539–58.
    1. Pogue JM, Yusuf S. Cumulating evidence from randomized trials: utilizing sequential monitoring boundaries for cumulative meta-analysis. Contr Clin Trials 1997;18:580–93. discussion 661–586.
    1. Forget P, Lois F, Kartheuser A, et al. The concept of titration can be transposed to fluid management. But does is change the volumes? Randomised trial on pleth variability index during fast-track colonic surgery. Curr Clin Pharmacol 2013;8:110–4.
    1. Zhang J, Qiao H, He Z, et al. Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Clinics 2012;67:1149–55.
    1. Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 2014;311:2181–90.
    1. Gustafsson UO, Scott MJ, Schwenk W, et al. Enhanced Recovery After Surgery Society fPC, European Society for Clinical N, Metabolism, International Association for Surgical M, Nutrition Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013;37:259–84.
    1. Mauermann WJ, Nemergut EC. The anesthesiologist's role in the prevention of surgical site infections. Anesthesiology 2006;105:413–21.
    1. Yuan J, Sun Y, Pan C, et al. Goal-directed fluid therapy for reducing risk of surgical site infections following abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. Int J Surg (London, England) 2017;39:74–87.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren