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Yang D, Hou X, Fu H, Song W, Dong W, Wang H, Mao Y, Li M, Chen J, He Y. Gastric residual volume, safety, and effectiveness of drinking 250 mL of glucose solution 2-3 hours before surgery in gastric cancer patients: a multicenter, single-blind, randomized-controlled trial. Gastroenterol Rep (Oxf) 2024; 12:goae077. [PMID: 39281267 PMCID: PMC11398872 DOI: 10.1093/gastro/goae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/06/2024] [Accepted: 06/10/2024] [Indexed: 09/18/2024] Open
Abstract
Background Carbohydrate drinking 2-3 hours before surgery has been widely adopted in colorectal operations. However, there is little direct evidence regarding its application in gastric cancer surgery. We aimed to evaluate the gastric residual volume, safety, and effectiveness of drinking 250 mL of 5% glucose solution 2-3 hours before elective gastric cancer surgery. Methods We conducted an investigator-initiated, multicenter, randomized-controlled, parallel group, and equivalence trial. Eighty-eight patients with gastric adenocarcinoma were randomized into study or control group. Patients in the control group followed the traditional routine of 6-8 hours preoperative fasting, while those in the study group drank 250 mL of 5% glucose solution 2-3 hours before surgery. Immediately following tracheal intubation, gastric contents were aspirated through gastroscopy. The primary outcome was preoperative gastric residual volume. Results Eighty-three patients were eventually analysed in the study (42 in the study group and 41 in the control group). Two groups were comparable at baseline characteristics. There were no statistical differences in residual gastric fluid volumes (35.86 ± 27.13 vs 27.70 ± 20.37 mL, P = 0.135) and pH values (2.81 ± 1.99 vs 2.66 ± 1.68, P = 0.708) between the two groups. Preoperative discomfort was significantly more decreased in the study group than in the control group (thirst score: 1.49 ± 1.23 vs 4.14 ± 2.07, P < 0.001; hunger score: 1.66 ± 1.18 vs 3.00 ± 2.32, P = 0.007). There was no statistical difference in the incidence of postoperative complications (19.05% vs 17.07%, P = 0.815). Conclusions Drinking 250 mL of 5% glucose solution 2-3 hours before surgery in elective gastric cancer patients shows benefits in lowering thirst and hunger scores without increasing gastric residual volume and perioperative complications.
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Affiliation(s)
- Dongjie Yang
- Digestive Medicine Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, Shenzhen, Guangdong, P. R. China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Xun Hou
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Huafeng Fu
- Digestive Medicine Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, P. R. China
| | - Wu Song
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Wenqing Dong
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Hu Wang
- Department of Gastrointestinal Surgery, The Forth Military Medical University Xijing Hospital, Xi'an, Shaanxi, P. R. China
| | - Yuantian Mao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Mengbin Li
- Department of Gastrointestinal Surgery, The Forth Military Medical University Xijing Hospital, Xi'an, Shaanxi, P. R. China
| | - Junqiang Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Yulong He
- Digestive Medicine Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, P. R. China
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, Shenzhen, Guangdong, P. R. China
- Research Center for Diagnosis and Treatment of Gastric Cancer, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
- Center for Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Guo L, Liu P, Jiang X, Shan Z, Wang R, Wang Z. Effects of oral carbohydrate loading in patients scheduled for painless bidirectional endoscopy: a prospective randomized controlled trial. Langenbecks Arch Surg 2024; 409:275. [PMID: 39254773 PMCID: PMC11387436 DOI: 10.1007/s00423-024-03468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 09/02/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE Traditional fasting causes considerable discomfort without added assurance of security, whereas oral carbohydrate beverage offers an alternative to improve medical experience. This study aims to explore the impact of different types and dosages of oral fluids loading before painless bidirectional endoscopy on the gastric emptying and wellbeing. METHODS 180 patients arranged for bidirectional endoscopy with intravenous anesthesia were randomized: patients in the control group (Group C) obeyed standard fasting; the 200 mL carbohydrate group (Group P1), 400 mL carbohydrate group (Group P2), 200 mL water group (Group W1) and 400 mL water group (Group W2) respectively consumed 200 mL or 400 mL corresponding clear liquids 2 h before the procedure. Gastric emptying metrics under ultrasound, subjective comfort indexes, periprocedural blood glucose and vital signs were contrasted among the groups. RESULTS No significant differences were detected in the gastric emptying including CSA (cross-sectional area), GV (gastric volume), cGV (corrected gastric volume) and the three-point grading system among groups, and none had a cGV > 1.5 mL/kg before anesthesia. Participants in Group P2 experienced less preprocedural thirst and mouth dryness, so as the postprocedural thirst, mouth dryness and hunger. Periprocedural blood glucose and MAP had the similar trend in all groups. The occurrence of hypotension, bradycardia, hypoxia, and the required norepinephrine was comparable among the groups. CONCLUSIONS Oral beverage loading with 200 mL or 400 mL can be safely applicated 2 h before painless bidirectional endoscopy without increasing the gastric volume. 400 mL carbohydrate solution effectively relieves the discomfort and could serve as a consideration. TRIAL REGISTRATION Registered in the Chinese Clinical Trial Registry on December 5, 2023 (ChiCTR2300078319).
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Affiliation(s)
- Lan Guo
- Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Pengfei Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, China
| | - Xinyue Jiang
- Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Zhengru Shan
- Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China
| | - Rui Wang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, China
| | - Zhiping Wang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221002, China.
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, 221004, China.
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Kitsiripant C, Rujirapat T, Chatmongkolchart S, Tanasansuttiporn J, Khanungwanitkul K. Comparison of Gastric Residual Volume After Ingestion of A Carbohydrate Drink and Water in Healthy Volunteers with Obesity: A Randomized Crossover Study. Obes Surg 2024:10.1007/s11695-024-07493-x. [PMID: 39235689 DOI: 10.1007/s11695-024-07493-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/24/2024] [Accepted: 08/27/2024] [Indexed: 09/06/2024]
Abstract
INTRODUCTION Preoperative carbohydrate intake is essential to enhance postoperative recovery. However, its safety for individuals with obesity remains unclear. This study investigated the safety of preoperative carbohydrate consumption compared to water intake in obese populations through gastric volume assessment. METHODS A prospective randomized crossover study enrolled 30 healthy volunteers aged 18-65 years with a body mass index ≥ 30 kg/m2, following a minimum 6-h fast. The participants received either 400 ml of a carbohydrate drink (group C) or water (group W). Gastric ultrasonography, blood glucose level, hunger, and thirst assessments were conducted at baseline (T) and various time points (T2 to T6). The protocol was repeated with reverse interventions at least 1 week later. RESULTS Group C had significantly higher gastric volume at T3, T4, and T5 compared to group W, with a prolonged time to empty the gastric antrum (94.4 ± 28.5 vs. 61.0 ± 33.5 min, 95% CI 33.41 [17.06,24.69]). However, glucose levels, degrees of hunger, and thirst showed no significant differences between the groups. CONCLUSION Administering 400 ml of preoperative carbohydrates to healthy obese individuals 2 h preoperatively is safe and comparable to water intake. These findings support the integration of carbohydrate loading into perioperative care for obese individuals, consistent with the enhanced recovery after surgery protocols. Further research is warranted to refine preoperative fasting protocols and improve surgical outcomes in this population.
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Affiliation(s)
- Chanatthee Kitsiripant
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, 90110, Songkhla, Thailand.
| | - Thipok Rujirapat
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, 90110, Songkhla, Thailand
| | - Sunisa Chatmongkolchart
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, 90110, Songkhla, Thailand
| | - Jutarat Tanasansuttiporn
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, 90110, Songkhla, Thailand
| | - Khanin Khanungwanitkul
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hatyai, 90110, Songkhla, Thailand
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Rajan N, Duggan EW, Abdelmalak BB, Butz S, Rodriguez LV, Vann MA, Joshi GP. Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery. Anesth Analg 2024; 139:459-477. [PMID: 38517760 DOI: 10.1213/ane.0000000000006791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting. What Other Guidelines Are Available on This Topic? Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. How Does This Guideline Differ From the Previous Guidelines? Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.
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Affiliation(s)
- Niraja Rajan
- From the Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
| | - Elizabeth W Duggan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Birmingham, Birmingham, Alabama
| | - Basem B Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Anesthesia for Bronchoscopic Surgery, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven Butz
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter, Milwaukee, Wisconsin
| | - Leopoldo V Rodriguez
- Department of Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, UCHealth Longs Peak Hospital and Surgery Center, Boulder Community Health, Foothills Hospital, Boulder, Colorado
| | - Mary Ann Vann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
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Chao NT, Karwoski AS, Pitsenbarger LT, Som MN, Dunlap E, Nagarsheth KH. Preoperative Nil Per Os Duration Predicts Mortality and Ambulation Following Below-Knee Amputation. Am Surg 2024; 90:2032-2041. [PMID: 38561237 DOI: 10.1177/00031348241244633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Routine use of nil per os (NPO) prior to procedures has been associated with dehydration and malnutrition leading to patient discomfort. We aim to examine how duration of NPO status affects postoperative outcomes in patients undergoing elective below-knee amputation (BKA). METHODS We performed a retrospective chart review of 92 patients who underwent elective BKA between 2014-2022 for noninfectious indications. We performed statistical analysis using Chi-square tests, t-tests, and linear/logistic regression with odds ratio using P < .05 as our significance level. RESULTS The mean age was 48.0 ± 16.7 years, and there were 64 (70%) male patients and 41 (45%) Black patients. Mean NPO duration was 12.9 ± 4.7 hours. Patients with longer NPO duration were associated with increased rates of postoperative stroke (P = .03). Patients with shorter NPO duration had significantly lower mean BUN on postoperative day (POD) 1 (14.5, P < .001) and POD 3 (14.1, P < .001) compared to preoperative mean BUN (16.8), however this normalized by POD 7 (19.2, P = .26). There were no changes in postoperative renal function based on baseline kidney disease status or associated with longer NPO duration. Shorter NPO duration was a predictor of increased likelihood of 1-year follow-up (OR: 2.9 [1.24-6.79], P = .01), independent ambulation (OR: 2.7 [1.03-7.34], P = .04), and decreased mortality (OR: .11 [.013-.91], P = .04). CONCLUSION While NPO duration does not appear to result in postoperative renal dysfunction, prolonged NPO duration predicts worse rates of follow-up, ambulation, and survival and is associated with increased stroke rates.
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Affiliation(s)
- Natalie T Chao
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Maria N Som
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eleanor Dunlap
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Vascular Division, University of Maryland Medical Center, Baltimore, MD, USA
| | - Khanjan H Nagarsheth
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, Vascular Division, University of Maryland Medical Center, Baltimore, MD, USA
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Iresjö BM, Smedh U, Engström C, Persson J, Mårtensson C, Lundholm K. A randomized translational study on protein- and glucose metabolism in skeletal muscles evaluated by gene-ontology, following preoperative oral carbohydrate loading compared to overnight peripheral parenteral nutrition (PPN) before major cancer surgery. J Transl Med 2024; 22:675. [PMID: 39039509 PMCID: PMC11265369 DOI: 10.1186/s12967-024-05484-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 07/03/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Effects of preoperative drinks on muscle metabolism are unclear despite general recommendations. The aim of the present study was therefore to compare metabolic effects of a preoperative oral nutrition drink, recommended by protocols for enhanced recovery after surgery (ERAS), compared to overnight preoperative peripheral total parenteral nutrition (PPN) on skeletal muscle metabolism in patients aimed at major gastrointestinal cancer surgery. METHODS Patients were randomized, based on diagnosis and clinical characteristics, to receive either a commercial carbohydrate-rich nutrition drink (Drink); or overnight (12 h) peripheral parenteral nutrition (PPN) as study regimens; compared to isotone Ringer-acetate as Control regimen. Arterial blood- and abdominal muscle tissue specimens were collected at start of surgery. Blood chemistry included substrate- and hormone concentrations. Muscle mRNA transcript analyses were performed by microarray and evaluated for changes in gene activities by Gene Ontology algorithms. RESULTS Patient groups were comparable in all measured preoperative assessments. The Nutrition Drink had significant metabolic alterations on muscle glucose metabolism (p < 0.05), without any significant effects on amino acid- and protein metabolism. PPN showed similar significant effects on glucose metabolism as Drinks (p < 0.05), but indicated also major positive effects on amino acid- (p < 0.001) and protein anabolism (p < 0.05), particularly by inhibition of muscle protein degradation, related to both ubiquitination of proteins and autophagy/lysosome pathways (p < 0.05). CONCLUSION Conventional overnight preoperative PPN seems effective to induce and support improved muscle protein metabolism in patients aimed at major cancer surgery while preoperative oral carbohydrate loading, according to ERAS-protocols, was ineffective to improve skeletal muscle catabolism and should therefore not be recommended before major cancer surgery. Trial registration Clinical trials.gov: NCT05080816, Registered June 10th 2021- Retrospectively registered. https://clinicaltrials.gov/study/NCT05080816.
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Affiliation(s)
- Britt-Marie Iresjö
- Institute of Clinical Sciences, Department of Surgery, Surgical Metabolic Research Lab, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | - Ulrika Smedh
- Institute of Clinical Sciences, Department of Surgery, Surgical Metabolic Research Lab, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cecilia Engström
- Institute of Clinical Sciences, Department of Surgery, Surgical Metabolic Research Lab, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Persson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Mårtensson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kent Lundholm
- Institute of Clinical Sciences, Department of Surgery, Surgical Metabolic Research Lab, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Canelli RJ, Louca J, Gonzalez RM, Rendon LF, Hartman CR, Bilotta F. Trends in preoperative carbohydrate load practice: A systematic review. JPEN J Parenter Enteral Nutr 2024; 48:527-537. [PMID: 38676554 DOI: 10.1002/jpen.2633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/22/2024] [Accepted: 04/05/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The preoperative carbohydrate load (PCL) is intended to improve surgical outcomes by reducing the catabolic state induced by overnight fasting. However, there is disagreement on the optimal PCL prescription, leaving local institutions without a standardized PCL recommendation. Results from studies that do not prescribe PCL in identical ways cannot be pooled to draw larger conclusions on outcomes affected by the PCL. The aim of this systematic review is to catalog prescribed PCL characteristics, including timing of ingestion, percentage of carbohydrate contribution, and volume, to ultimately standardize PCL practice. METHODS A comprehensive search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials were included if they studied at least one group of patients who were prescribed a PCL and the PCL was described with respect to timing of ingestion, carbohydrate contribution, and total volume. RESULTS A total of 67 studies with 6551 patients were included in this systematic review. Of the studies, 49.3% were prescribed PCL on the night before surgery and morning of surgery, whereas 47.8% were prescribed PCL on the morning of surgery alone. The mean prescribed carbohydrate concentration was 13.5% (±3.4). The total volume prescribed was 648.2 ml (±377). CONCLUSION Variation in PCL practices prevent meaningful data pooling and outcome analysis, highlighting the need for standardized PCL prescription. Efforts dedicated to the establishment of a gold standard PCL prescription are necessary so that studies can be pooled and analyzed with respect to meaningful clinical end points that impact surgical outcomes and patient satisfaction.
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Affiliation(s)
- Robert J Canelli
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Joseph Louca
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Rafael M Gonzalez
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Yap KS, Loh PS, Foong YX, Mok CZ, Ong T, Khor HM. A feasibility study on preoperative carbohydrate loading in older patients undergoing hip fracture surgery. BMC Geriatr 2024; 24:401. [PMID: 38711010 PMCID: PMC11075227 DOI: 10.1186/s12877-024-04958-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Preoperative carbohydrate loading in Enhanced Recovery After Surgery is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming carbohydrate drink is safe up to 2 h preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. This study aimed to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. METHODS This was a randomized controlled, open labelled trial. Patients ≥ 65 years old without diabetes mellitus, has hip fracture were recruited in a tertiary hospital between November 2020 and May 2021. The intervention was carbohydrate loading versus standard preoperative fasting. RESULTS Thirty-four ASA I-III patients (carbohydrate loading and control, n = 17 each), mean age 78 years (SEM ± 1.5), mean body mass index 23.7 (SEM ± 0.6 kg/m2) were recruited. Analysis for feasibility of carbohydrate loading (n = 17) demonstrated attrition rate of 29% (n = 5). Otherwise, all recruited patients were compliant (100% compliance) with no adverse events reported. There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level, muscle strength, postoperative infection and length of hospital stay assessed at 24-48 h postoperatively. CONCLUSION The implementation of preoperative carbohydrate loading was found to be feasible preoperatively in hip fracture surgeries but requires careful coordination among multidisciplinary teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients. TRIAL REGISTRATION This study was registered in ClinicalTrial.gov (ClinicalTrials.gov identifier: NCT04614181, date of registration: 03/11/2020).
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Affiliation(s)
- Kai Sing Yap
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - P S Loh
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Yi Xian Foong
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chu Zhen Mok
- Department of Dietetics, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Terence Ong
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Zhang H, Liu H, Zhang X, Zhao M, Guo D, Bai Y, Qi X, Shi H, Li D. Short-term outcomes of an enhanced recovery after surgery pathway for children with congenital scoliosis undergoing posterior spinal fusion: a case-control study of 70 patients. J Pediatr Orthop B 2024; 33:258-264. [PMID: 37339529 DOI: 10.1097/bpb.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Increasing evidence demonstrates the advantages of an enhanced recovery after surgery (ERAS) protocol; however, few studies have evaluated ERAS in pediatric patients. This study aimed to evaluate the effect of ERAS in pediatric patients with congenital scoliosis. Seventy pediatric patients with congenital scoliosis underwent posterior hemivertebra resection and fusion with pedicle screws and were prospectively randomly assigned to the ERAS group ( n = 35) and control group ( n = 35). ERAS management comprised 15 elements including a shortened fasting time, optimized anesthesia protocol, and multimodal analgesia. The control group received traditional perioperative management. Clinical outcome was evaluated by hospital stay, surgery-related indicators, diet, pain scores, laboratory tests, and complications. The surgical outcome showed a similar correction rate in the ERAS group (84.0%) and control group (89.0%; P = 0.471). The mean fasting time was significantly shorter in the ERAS group than in the control group. Compared with the control group, the ERAS group had significantly shorter mean times to postoperative hospital stay, first anal exhaust and defecation, significantly lower mean pain scores in the first 2 days postoperatively ( P < 0.05), and a significantly lower mean interleukin-6 concentration on postoperative day 1 ( P < 0.001). The incidence of complications was similar in the ERAS group and control group ( P > 0.05). The ERAS protocol is effective and safe for pediatric patients with congenital spinal deformity and may significantly improve the treatment efficacy compared with traditional perioperative management methods. Levels of Evidence: III.
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Affiliation(s)
- Hanwen Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haonan Liu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xuejun Zhang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Mengqi Zhao
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Dong Guo
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Yunsong Bai
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Xinyu Qi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Haixia Shi
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health
| | - Duoyi Li
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Wang X, Zhuang J, Cheng J, Wang Z, Sheng J, Guo S, Wang R, Wang Z. Effect of preoperative oral carbohydrates on insulin resistance in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial. Langenbecks Arch Surg 2024; 409:77. [PMID: 38411704 PMCID: PMC10899310 DOI: 10.1007/s00423-024-03268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE The present research seeks to clarify the consequences of two specific preoperative oral carbohydrate (POC) amounts on insulin resistance (IR) and stomach evacuation in laparoscopic cholecystectomy (LC) patients. METHODS A total of 129 patients set for elective LC procedures were randomly assigned to a control group (C, n = 45), a 200 mL POC group (P1, n = 42), and a 400 mL POC group (P2, n = 42). The C group was fasted from midnight until surgery, whereas the P1 and P2 groups received their respective carbohydrate volumes 2-4 h before anesthesia. Fasting blood glucose, insulin, and glucagon concentrations were measured at three junctures. IR metrics were derived by employing the homeostasis model assessment. Gastric volume was measured before anesthesia using gastric ultrasound. Inter-group comparisons included IR indicators, subjective comfort scores, and hemodynamic data. RESULTS At T2, the C group exhibited reduced glucose concentrations compared to the P2 group (4.73 ± 0.64 vs. 5.26 ± 1.02 mmol/L, p < 0.05). The Perlas grading indicated that grade 1 was more prevalent in the P2 group than in the P1 and C groups (18 [42.9%] vs. 6 [14.3%] and 1 [2.2%], p < 0.05). Additionally, thirst and hunger metrics for the P2 group were notably reduced compared to the C group at both T2 and T3. CONCLUSION Administering either 200 mL or 400 mL of carbohydrates 2-4 h pre-surgery had no detectable impact on IR or gastric volume in LC patients. TRIAL REGISTRATION ChiCTR, ChiCTR2200065648. Registered January 13, 2023, http://www.chictr.org.cn .
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Affiliation(s)
- Xiaohan Wang
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Jingwen Zhuang
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Jianxin Cheng
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Zeyang Wang
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Jingyi Sheng
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Shanshan Guo
- Xuzhou Medical University, Xuzhou, 221004, Jiangsu, China
| | - Rui Wang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, China
| | - Zhiping Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, 209 Tongshan Road, Xuzhou, 221004, Jiangsu, China.
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, Jiangsu, China.
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11
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Zhu J, Jin XQ, Li XY, Sun L, Peng Y. The association between oral carbohydrate intake before orthopedic surgery for osteoporotic fractures and outcomes in elderly patients. J Orthop Surg Res 2023; 18:966. [PMID: 38098008 PMCID: PMC10722799 DOI: 10.1186/s13018-023-04458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Oral carbohydrate (CHO) intake is a safe method with effective clinical results in various surgical patients before surgery. Nevertheless, due to a lack of adequate clinical data, it is not frequently utilized in older patients undergoing orthopedic surgery for osteoporotic fractures (OPFs), especially in China. The purpose of the present study was to examine the relationship between preoperative oral CHO consumption and outcomes in elderly patients undergoing surgical treatment for OPFs. METHODS This retrospective cohort study was conducted at a single Chinese institution and included a total of 879 elderly patients (median age: 71 years; range: 50-99 years) who underwent OPF surgery. Various exclusion criteria were established as follows: (a) the necessity for urgent surgical intervention; (b) the existence of hypoglycemia, hyperglycemia, or diabetes mellitus with blood glucose levels lower than 2.8 mmol/L; (c) a medical history of gastrointestinal motility disorders or delayed gastric emptying; (d) the utilization of local anesthesia; (e) a Charlson comorbidity index (CCI) score over 2; and (f) an American Society of Anesthesiologists (ASA) score exceeding 3. After propensity score (PS) matching, 264 patients from each cohort were included in the analysis. The primary outcome was the all-cause mortality rate within 60 days post-surgery, while secondary outcomes included the length of hospital stay (LOS), hospitalization costs, intraoperative and postoperative blood transfusions, and the incidence of postoperative nausea and vomiting (PONV) and aspiration. The relationship between preoperative oral CHO intake and outcomes was evaluated using multivariate regression analysis. RESULTS After PS matching, preoperative oral CHO intake was negatively associated with 60-day mortality in the fully adjusted model (odds ratio 0.35; 95% confidence interval 0.12-0.97; P-value: 0.04). Patients who received preoperative oral CHO intake also had a shorter LOS and lower hospitalization costs than those who did not receive CHO intake. However, none of the models showed a significant association between CHO intake and PONV or blood transfusion risk. Furthermore, no cases of aspiration were observed in either cohort. CONCLUSIONS Preoperative oral CHO intake may be associated with reduced mortality risk and improved outcomes in elderly patients undergoing surgical treatment for OPFs. However, it is important to acknowledge the limitations of our study, including its retrospective nature, potential unmeasured confounding variables, the small sample size, incomplete data on important variables such as duration of surgery and inflammatory markers, and the limited generalizability due to the participation of only one institution. Future research with larger sample sizes and a broader range of events is warranted to validate and enhance the validity of our findings, particularly in assessing long-term results and understanding the underlying mechanisms.
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Affiliation(s)
- Jing Zhu
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Xue-Qin Jin
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Xiao-Yan Li
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Li Sun
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Yuan Peng
- Intensive Care Unit, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, Jiangsu, China.
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12
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Hwang TZ, Wang YM, Jeng SF, Lee YC, Chen TS, Su SY, Huang CC, Lam CF. Intraoperative Enteral Nutrition Feeding in Free-Flap Healing after Reconstruction Surgery for Head and Neck Cancers. Otolaryngol Head Neck Surg 2023; 169:843-851. [PMID: 36960779 DOI: 10.1002/ohn.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/31/2023] [Accepted: 02/26/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To investigate the beneficial outcomes of intraoperative enteral feeding in free-flap regeneration after extended head and neck cancer resection and flap reconstruction surgery. STUDY DESIGN A pilot randomized, double-blind, placebo-controlled clinical trial. SETTING Single tertiary care center. METHODS Patients with advanced head and neck cancers requiring radical tumor resections and free-flap reconstruction were randomly assigned to receive intraoperative enteral nutrition feeding (100 kcal/100 mL at 10-20 mL/h) via a nasogastric tube during free-flap reconstruction (n = 28) or continue fasting (n = 28). The primary outcome was impaired free-flap regeneration that required surgical reintervention within 90 days after the operation. Participants were enrolled between April 2020 and January 2022; the 90-day follow-up ended in April 2022. RESULTS The incidence of total or partial flap failure was similar between the 2 groups (14.2% or n = 4 in each group), but the rate of wound dehiscence or edge necrosis was significantly reduced in the feeding group (n = 6 vs 0 for fasting vs feeding; absolute risk reduction, 25.0% [95% confidence interval, 6.9-43.0]%; p = 0.022). Hospital stay length was shorter (p = 0.042) and hand grip strength was better preserved (p = 0.025) in the feeding group. Plasma concentrations of interleukin (IL)-6 and IL-8 after the operation increased significantly more in the fasting group. Perioperative adverse events did not differ between the 2 groups. CONCLUSION Perioperative enteral feeding is a simple, safe, and effective approach to improve perioperative systemic catabolism and proinflammatory reactions, thereby enhancing early wound regeneration after major operations.
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Affiliation(s)
- Tzer-Zen Hwang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Ming Wang
- Department of Critical Care Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Seng-Feng Jeng
- Department of Plastic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Chen Lee
- Department of Nutrition Therapy, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
- Department of Nutrition, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Shan Chen
- Department of Medical Research, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Shin-Ying Su
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chien-Chi Huang
- Department of Medical Research, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- Department of Anesthesiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan
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13
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Jain SN, Lamture Y, Krishna M. Enhanced Recovery After Surgery: Exploring the Advances and Strategies. Cureus 2023; 15:e47237. [PMID: 38022245 PMCID: PMC10654132 DOI: 10.7759/cureus.47237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.
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Affiliation(s)
- Shubhi N Jain
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Malay Krishna
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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14
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Valla FV, Uberti T, Henry C, Slim K. Perioperative nutritional assessment and support in visceral surgery. J Visc Surg 2023; 160:356-367. [PMID: 37587003 DOI: 10.1016/j.jviscsurg.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.
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Affiliation(s)
- Frederic V Valla
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France.
| | - Thomas Uberti
- Anesthesiology and Critical Care Department, Hôpital E.-Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France
| | - Caroline Henry
- Nutrition Support Team, Hospices Civils de Lyon, 69310 Lyon - Pierre-Bénite, France
| | - Karem Slim
- Digestive Surgery Department and Ambulatory Surgery Unit, 63003 Clermont-Ferrand, France
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15
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Pettit MS, Crowder SL, Ackerman RS, Hafez O, Poch MA, Patel SY. Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature. Nutr Cancer 2023; 75:1743-1751. [PMID: 37553951 DOI: 10.1080/01635581.2023.2244172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.
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Affiliation(s)
- Matthew S Pettit
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Sylvia L Crowder
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert S Ackerman
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Osama Hafez
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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16
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Shao J, Xie J, Sun P, Zhang Y, Chen D, Chen Y, Xu M. Factors Influencing Postoperative Recovery Time of Patients With Gastric Cancer. Surg Laparosc Endosc Percutan Tech 2023; 33:370-374. [PMID: 37235717 DOI: 10.1097/sle.0000000000001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/31/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND To explore the factors associated with prolonged enhanced recovery after surgery (ERAS) time in gastric cancer patients who underwent gastrectomy. METHODS This was a retrospective of patients with gastric cancer who received ERAS at our hospital between 01/2014 and 01/2022. The outcome was prolonged ERAS time. Factors associated with prolonged ERAS time of patients undergoing gastric cancer surgery were analyzed by logistic regression. RESULTS Among 663 patients, 182 (27.6%) patients had a prolonged ERAS time. The postoperative time to the first flatus time was 2.8 ± 1.2 days. There were 41 (6.2%) patients with intestinal obstruction, 25 (3.8%) with abdominal infection, and four (0.5%) with anastomotic leakage. The multivariable analysis showed that age >80 years (OR = 1.57, 95% CI: 1.31-4.40, P = 0.048), laparoscopic surgery (OR = 0.45, 95% CI: 0.21-0.95, P = 0.035), intraoperative jejunostomy (OR = 334.60, 95% CI: 2.81-39,831.90, P = 0.017), postoperative time to the first flatus time (OR = 3.79, 95% CI: 1.23-11.68, P = 0.021), total gastrectomy (OR = 0.08, 95% CI: 0.01-0.94, P = 0.044), and patient compliance with ERAS (OR = 0.01, 95% CI: 0-0.09, P < 0.001) were independently associated with prolonged ERAS time. CONCLUSIONS Age >80 years, laparoscopic surgery, intraoperative jejunostomy, postoperative time to the first flatus time, total gastrectomy, and patient compliance with ERAS might be factors associated with prolonged ERAS time in gastric cancer patients.
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Affiliation(s)
- Jun Shao
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Jiang Xie
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Peng Sun
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Yunpeng Zhang
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Daqing Chen
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
| | - Ying Chen
- Department of Oncology, Shanghai Tongren Hospital, Shanghai China
| | - Ming Xu
- Department of General Surgery Gastrointestinal group, Shanghai Tongren Hospital
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17
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Ngo F, Urman RD, English W, Kothari S, DeMaria E, Wadhwa A. An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity. Surg Obes Relat Dis 2023; 19:171-177. [PMID: 36732143 DOI: 10.1016/j.soard.2022.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).
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Affiliation(s)
- Fallon Ngo
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Richard D Urman
- International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wayne English
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shanu Kothari
- Department of Surgery, University of South Carolina Greenville, Prisma Health - Greenville Memorial Medical Campus, Greenville, South Carolina.
| | - Eric DeMaria
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Anupama Wadhwa
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, Texas; International Society of Perioperative Care of Patients with Obesity, Lynnwood, Washington; Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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18
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Paine H, Jones F, Kinross J. Preparing the Bowel (Microbiome) for Surgery: Surgical Bioresilience. Clin Colon Rectal Surg 2023; 36:138-145. [PMID: 36844712 PMCID: PMC9946716 DOI: 10.1055/s-0042-1760675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The preparation of the bowel for radical surgery is a corner stone of elective colorectal practice. The evidence for this intervention is of variable quality and it is often contradictory, yet there is now a global move toward the adoption of oral antibiotic therapy for the reduction of perioperative infective complications, such as surgical site infections. The gut microbiome is a critical mediator of the systemic inflammatory response to surgical injury, wound healing, and perioperative gut function. The loss of critical microbial symbiotic functions caused by bowel preparation and surgery has an adverse impact on surgical outcomes, yet the mechanisms through which this occurs are poorly defined. In this review, the evidence for bowel preparation strategies is critically appraised in the context of the gut microbiome. The impact of antibiotic therapy on the surgical gut microbiome and the importance of the intestinal "resistome" to surgical recovery is described. Data to support the augmentation of the microbiome through diet, probiotic and symbiotic approaches, as well as fecal transplantation are also appraised. Finally, we propose a novel strategy of bowel preparation defined as " surgical bioresilience " and define areas or prioritization in this emerging field. This describes the optimization of surgical intestinal homeostasis and core surgical exposome-microbiome interactions that regulate the wound immune microenvironment, the systemic inflammatory response to surgical injury, and gut function across the perioperative time course.
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Affiliation(s)
- Heidi Paine
- Division of General Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Faye Jones
- Division of General Surgery, King Edward VII Hospital, London, United Kingdom
| | - James Kinross
- Division of Colorectal Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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19
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Noorian S, Kwaan MR, Jaffe N, Yaceczko SD, Chau LW. Perioperative nutrition for gastrointestinal surgery: On the cutting edge. Nutr Clin Pract 2023; 38:539-556. [PMID: 36847684 DOI: 10.1002/ncp.10970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/16/2023] [Accepted: 01/28/2023] [Indexed: 03/01/2023] Open
Abstract
Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.
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Affiliation(s)
- Shaya Noorian
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Mary R Kwaan
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Nancee Jaffe
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Lydia W Chau
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
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20
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Cassady BA, McDonald JD, Yalawar M, Baggs GE, Maki KC. Pilot study on the impact of a carbohydrate loading drink on postprandial glycemic responses and gastric emptying in adults with prediabetes and type 2 diabetes mellitus. Nutr Clin Pract 2023; 38:108-117. [PMID: 35118717 PMCID: PMC10078677 DOI: 10.1002/ncp.10845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/29/2021] [Accepted: 01/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Preoperative carbohydrate (CHO) loading improves patient outcomes but is not extensively studied in individuals with diabetes mellitus (DM), resulting in limited professional recommendations. This study examined postprandial glycemic responses and gastric emptying rates following consumption of a CHO drink in adults with and without DM. METHODS A single-arm, nonrandomized pilot trial was conducted in adults without DM (non-DM) (47.5 ± 2.5 years), with pre-DM (55.8 ± 3.0 years), and with type 2 DM (56.2 ± 2.5 years). Following an overnight fast, participants consumed a 50 g CHO drink followed by 1.5 g liquid paracetamol. Venous blood samples were collected at baseline (ie, t = 0 min) and 15, 30, 45, 60, 90, 120, 150, 180, 210, and 240 min for plasma glucose and serum insulin and paracetamol concentrations to assess gastric emptying. RESULTS Participants with DM were older and had a higher body mass index than non-DM participants (31.2 ± 0.9 vs 28.2 ± 0.9). Fasting glucose and hemoglobin A1c levels differed significantly across groups (non-DM: 95.4 ± 3.6 mg/dl and 5.2% ± 0.1%; pre-DM: 111.6 ± 3.6 mg/dl and 5.8% ± 0.1%; DM: 167.4 ± 3.6 mg/dl and 7.2% ± 0.1%). Compared with the non-DM group, DM had increased glucose responses at 30-180 min. Glucose returned to baseline at 150 min in the non-DM and pre-DM groups compared with 210 min in the DM group. Paracetamol concentrations were not significantly different between the non-DM and DM groups. CONCLUSION Blood glucose returned to baseline within ~2.5 h in non-DM and pre-DM groups and ~3.5 h in participants with DM following ingestion of a CHO drink. No consistent differences in gastric emptying rates were observed between participants with and without DM.
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Affiliation(s)
| | | | - Menaka Yalawar
- Statistical Services, Cognizant Technology Solutions Pvt Ltd, Bangalore, India
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21
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Abstract
Striving to optimize surgical outcomes, the Enhanced Recovery After Surgery (ERAS) pathway mitigates patients' stress through the implementation of evidence-based practices during the pre-, intra-, and postoperative periods. Intestinal flora is a sophisticated ecosystem integrating with the host and the external environment, which serves as a mediator in diverse interventions of ERAS to regulate human metabolism and inflammation. This review linked gut microbes and their metabolites with ERAS interventions, offering novel high-quality investigative proponents for ERAS. ERAS could alter the composition and function of intestinal flora in patients by alleviating various perioperative stress responses. Modifying gut flora through multiple modalities, such as diet and nutrition, to accelerate recovery might be a complementary approach when exploring novel ERAS initiatives. Meanwhile, the pandemic of COVID-19 and the availability of promising qualitative evidence created both challenges and opportunities for the establishment of ERAS mode.
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22
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Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 2023; 47:11-34. [PMID: 36310325 PMCID: PMC9726826 DOI: 10.1007/s00268-022-06732-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature. METHODS A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system. RESULTS A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy. CONCLUSIONS These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
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Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery. J Craniofac Surg 2023; 34:83-91. [PMID: 35968948 DOI: 10.1097/scs.0000000000008893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/04/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery. METHODS The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed. RESULTS The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population. CONCLUSION Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.
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Ji N, Xiang L, Zhou B, Lu Y, Zhang M. Hepatic gene expression profiles during fed-fasted-refed state in mice. Front Genet 2023; 14:1145769. [PMID: 36936413 PMCID: PMC10020372 DOI: 10.3389/fgene.2023.1145769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background: Regulation of nutrient status during fasting and refeeding plays an important role in maintaining metabolic homeostasis in the liver. Thus, we investigated the impact of the physiological Fed-Fast-Refed cycle on hepatic gene expression in nutrient-sensitive mice. Methods: We performed transcriptomic analysis of liver samples in fed, fasted and refed groups of mice. Through mRNA-sequencing (RNA-Seq) and miRNA-Seq, we compared fasted and fed states (fasted versus fed cohort) as well as refed and fasted states (refed versus fasted cohort) to detect dynamic alterations of hepatic mRNA-miRNA expression during the fed-fasted-refed cycle. Results: We found dozens of dysregulated mRNAs-miRNAs in the transition from fed to fasted and from fasted to refed states. Gene set enrichment analysis showed that gene expression of the two cohorts shared common pathways of regulation, especially for lipid and protein metabolism. We identified eight significant mRNA and three miRNA clusters that were up-downregulated or down-upregulated during the Fed-Fast-Refed cycle. A protein-protein interaction network of dysregulated mRNAs was constructed and clustered into 22 key modules. The regulation between miRNAs and target mRNAs was presented in a network. Up to 42 miRNA-mRNA-pathway pairs were identified to be involved in metabolism. In lipid metabolism, there were significant correlations between mmu-miR-296-5p and Cyp2u1 and between mmu-miR-novel-chr19_16777 and Acsl3. Conclusion: Collectively, our data provide a valuable resource for the molecular characterization of the physiological Fed-Fast-Refed cycle in the liver.
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Affiliation(s)
- Nana Ji
- Department of Endocrinology and Metabolism, Qingpu Branch of Zhongshan Hospital affiliated to Fudan University, Shanghai, China
| | - Liping Xiang
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Diabetes Institute, Shanghai Clinical Centre for Diabetes, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Zhou
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Diabetes Institute, Shanghai Clinical Centre for Diabetes, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Lu
- Institute of Metabolism and Regenerative Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Zhang
- Department of Endocrinology and Metabolism, Qingpu Branch of Zhongshan Hospital affiliated to Fudan University, Shanghai, China
- *Correspondence: Min Zhang,
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Zhang J, Chi R, Zhang Y, Xie Y, Liu Y, Bao Q, Lv H, Han B, Sun H, Sun P. Preoperative administration of branched-chain amino acids reduces postoperative insulin resistance in rats by reducing liver gluconeogenesis. Nutr Metab (Lond) 2022; 19:78. [PMID: 36447227 PMCID: PMC9706859 DOI: 10.1186/s12986-022-00710-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/30/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Postoperative insulin resistance (PIR) represents an important characteristic of metabolic response following surgical injury. Clinical outcomes are negatively correlated to postoperative insulin resistance and hyperglycemia, indicating a novel treatment for reducing postoperative insulin resistance is urgently needed. The current work aimed to assess the protective effects of branched-chain amino acids (BCAA) on glucose metabolism disorders induced surgically in a rat model, and to explore the underpinning mechanism. METHODS AND RESULTS Rats were randomly assigned to 2 groups, including the control and BCAA groups. Rats were given a compulsory oral 3 mL load by gavage two hours before surgery. The results showed that BCAA remarkably reduced glycemia by suppressing liver gluconeogenesis via reduction of cAMP-response element-binding protein-regulated transcription coactivator 2 (CRTC2) and glucose-6-phosphatase (G6PC) gene and protein expression levels (all Ps < 0.05). CONCLUSIONS This study revealed that BCAA lower blood glucose levels by reducing liver gluconeogenesis without significant elevation of plasma insulin levels. We anticipate that preoperative BCAA supplementation may be a means for preventing postoperative insulin resistance.
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Affiliation(s)
- Jin Zhang
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Rui Chi
- grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Yunpeng Zhang
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Yi Xie
- grid.16821.3c0000 0004 0368 8293Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Yunxia Liu
- grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Qun Bao
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Hengyu Lv
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Bo Han
- grid.16821.3c0000 0004 0368 8293Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Haipeng Sun
- grid.265021.20000 0000 9792 1228NHC Key Laboratory of Hormones and Development, Center for Cardiovascular Diseases, The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, 300134 China ,grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Peng Sun
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
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Tong E, Chen Y, Ren Y, Zhou Y, Di C, Zhou Y, Shao S, Qiu S, Hong Y, Yang L, Tan X. Effects of preoperative carbohydrate loading on recovery after elective surgery: A systematic review and Bayesian network meta-analysis of randomized controlled trials. Front Nutr 2022; 9:951676. [PMID: 36505254 PMCID: PMC9726728 DOI: 10.3389/fnut.2022.951676] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Preoperative carbohydrate loading is an important element of the enhanced recovery after surgery (ERAS) paradigm in adult patients undergoing elective surgery. However, preoperative carbohydrate loading remains controversial in terms of improvement in postoperative outcomes and safety. We conducted a Bayesian network meta-analysis to evaluate the effects and safety of different doses of preoperative carbohydrates administrated in adult patients after elective surgery. Methods MEDLINE (PubMed), Web of Science, EMBASE, EBSCO, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure (CNKI) were searched to identify eligible trials until 16 September 2022. Outcomes included postoperative insulin resistance, residual gastric volume (RGV) during the surgery, insulin sensitivity, fasting plasma glucose (FPG), fasting serum insulin (Fin) level, the serum levels of C-reactive protein (CRP), postoperative scores of pain, patients' satisfaction, thirst, hunger, anxiety, nausea and vomit, fatigue, and weakness within the first 24 h after surgery and the occurrences of postoperative infection. The effect sizes were estimated using posterior mean difference (continuous variables) or odds ratios (dichotomous variables) and 95 credible intervals (CrIs) with the change from baseline in a Bayesian network meta-analysis with random effect. Results Fifty-eight articles (N = 4936 patients) fulfilled the eligibility criteria and were included in the meta-analysis. Both preoperative oral low-dose carbohydrate loading (MD: -3.25, 95% CrI: -5.27 to -1.24) and oral high-dose carbohydrate loading (MD: -2.57, 95% CrI: -4.33 to -0.78) were associated with postoperative insulin resistance compared to placebo/water. When trials at high risk of bias were excluded, association with insulin resistance was found for oral low-dose carbohydrate loading compared with placebo/water (MD: -1.29, 95%CrI: -2.26 to -0.27) and overnight fasting (MD: -1.17, 95%CrI: -1.88 to -0.43). So, there was large uncertainty for all estimates vs. control groups. In terms of safety, oral low-dose carbohydrate administration was associated with the occurrences of postoperative infection compared with fasting by 0.42 (95%Crl: 0.20-0.81). In the other outcomes, there was no significant difference between the carbohydrate and control groups. Conclusion Although preoperative carbohydrate loading was associated with postoperative insulin resistance and the occurrences of postoperative infection, there is no evidence that preoperative carbohydrate administration alleviates patients' discomfort. Systematic review registration [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022312944].
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Affiliation(s)
- Enyu Tong
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Yiming Chen
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Yanli Ren
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Yuanyuan Zhou
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Chunhong Di
- The Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, China
| | - Ying Zhou
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Shihan Shao
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Shuting Qiu
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Yu Hong
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Lei Yang
- School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Xiaohua Tan
- School of Public Health, Hangzhou Normal University, Hangzhou, China
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Liddle C. Preoperative fasting: exploring guidelines and evidence to ensure consistent, high-quality care. Nurs Stand 2022; 37:77-82. [PMID: 36377391 DOI: 10.7748/ns.2022.e12033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 11/16/2022]
Abstract
Many nurses will still be familiar with the instruction 'nil by mouth from midnight' traditionally given to patients preparing to undergo surgery. National and international guidelines now promote much shorter preoperative fasting times, encapsulated in the '2-4-6 rule' - two hours for clear fluids, four hours for breast milk and six hours for solids. The latest evidence appears to show that these fasting times are in need of revision. Furthermore, there are inconsistencies in how guidelines are implemented. This article explores the guidelines and literature on preoperative fasting in adults and children to determine what the evidence is and what changes could be made to ensure consistent, high-quality patient care.
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Enhanced recovery after surgery is feasible and safe in liver transplantation: a cohort study. HPB (Oxford) 2022; 24:2022-2028. [PMID: 35973930 DOI: 10.1016/j.hpb.2022.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/22/2022] [Accepted: 07/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The principles of enhanced recovery after surgery (ERAS) are being applied to still more advanced procedures. Liver transplantation offers a unique opportunity for a multimodal approach including donor care as well. Our objective was to determine if ERAS was applicable and safe in orthotopic liver transplantation (OLT). METHODS A national single centre retrospective study showing the implementation of ERAS from 2013 to 2019 with the proceeding 2 years serving as baseline. The primary endpoints were mortality, length of stay (LOS) in the ward and intensive care unit stay. Secondary endpoints were complications estimated by Dindo-Clavien classification, comprehensive complication index (CCI®) and re-admissions. RESULTS A total of 334 patients were included. LOS was significantly reduced from a median of 22.5 days at introduction to 14 days at 2019. Cold ischaemia time was reduced from a mean of 10.7 to 6.0 h and the use of blood products (erythrocytes, plasma and thrombocytes) from a median of 28 to 6 units. Complications were reduced in severity. Mortality and readmission rates were not affected. CONCLUSION ERAS principles are safe and recommended in patients undergoing OLT resulting in reduced severity of complications and LOS without affecting re-admissions or mortality.
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Chaudhary NK, Sunuwar DR, Sharma R, Karki M, Timilsena MN, Gurung A, Badgami S, Singh DR, Karki P, Bhandari KK, Pradhan PMS. The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial. BMC Musculoskelet Disord 2022; 23:819. [PMID: 36042436 PMCID: PMC9424836 DOI: 10.1186/s12891-022-05766-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Femur fracture is a major burden among elderly people, leading patients to be bedridden for a long time in the hospital. The body is more likely to be in a catabolic state as a result of the prolonged fasting period required for surgery, leading to an increase in insulin resistance. Pre-operative carbohydrate loading has been shown to improve postoperative outcomes in several countries. The study aimed to evaluate the effect of pre-operative carbohydrate loading in femur fracture surgery. METHODS This study was single-center, hospital-based, open-label, parallel-group randomized controlled trial conducted between August 2020 and November 2021. A total of 66 participants, aged 50 years and above having femur fractures planned for surgery were included in this study and assigned to the control (n = 33) and study (n = 33) groups through computer-generated random numbers. The control group was kept fasting from midnight to the next morning as in existence while the study group was intervened with carbohydrate loading according to the Enhanced Recovery After Surgery (ERAS) protocol. The pre-operative nutritional status was identified and the postoperative outcomes were measured using the Visual Analogue Score (VAS), Cumulative Ambulatory Score (CAS), and Modified Barthel Index (MBI) scoring systems. Statistical analyses were performed using the Chi-square test and the Student's two-sample t-test to compare the outcomes between the two groups. RESULTS All the participants completed the study. There was a significant reduction in the average postoperative pain in the carbohydrate loading group (VAS: 4.8 (SD ± 1.8), 95% CI: 4.7-5.4) as compared to the control group (VAS: 6.1 (SD ± 2.1), 95% CI: 5.3-6.8). The average CAS showed a significant improvement in regaining the mobility function of participants in the study group (CAS: 8.1 (SD ± 2.8), 95% CI: 7.1-9.1) than that of the control group (CAS: 6.8 (SD ± 2.8), 95% CI: 5.8-7.8). The mean MBI score of the participants at the time of discharge from the hospital was higher in the study group (MBI:13.1 (SD ± 2.3), 95% CI: 12.2-13.9) compared to the control group (MBI: 11.8 (SD ± 3.1), 95% CI:10.6-12.9). Similarly, the length of hospital stay after surgery had decreased in the study group than in the control group. CONCLUSIONS The uptake of carbohydrate loading showed reduced post-operative pain, enhanced functional mobility, and decreased length of hospital stay. This study warrants larger trials to show the effect of pre-operative carbohydrate loading in a clinical setting. TRIAL REGISTRATION NCT04838366, first registered on 09/042021 ( https://clinicaltrials.gov/ct2/show/NCT04838366 ).
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Affiliation(s)
| | - Dev Ram Sunuwar
- Department of Nutrition and Dietetics, Armed Police Force Hospital, Kathmandu, Nepal
| | | | | | | | | | | | - Devendra Raj Singh
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Prabesh Karki
- Greentara College of Health Sciences, Lalitpur, Nepal
| | | | - Pranil Man Singh Pradhan
- Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Sun ZJ, Sun X, Huo Y, Mi M, Peng GL, Zhang CL, Jiang Y, Zhou Y, Zhao X, Li T, Wu XB. Abbreviated perioperative fasting management for elective fresh fracture surgery: guideline adherence analysis. BMC Musculoskelet Disord 2022; 23:688. [PMID: 35858882 PMCID: PMC9297612 DOI: 10.1186/s12891-022-05574-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term fasting for elective surgery has been proven unnecessary based on established guidelines. Instead, preoperative carbohydrate loading 2 h before surgery and recommencing oral nutrition intake as soon as possible after surgery is recommended. This study was performed to analyze the compliance with and effect of abbreviated perioperative fasting management in patients undergoing surgical repair of fresh fractures based on current guidelines. METHODS Patients with fresh fractures were retrospectively analyzed from the prospectively collected database about perioperative managements based on enhanced recovery of surgery (ERAS) from May 2019 to July 2019 at our hospital. A carbohydrate-enriched beverage was recommended up to 2 h before surgery for all surgical patients except those with contraindications. Postoperatively, oral clear liquids were allowed once the patients had regained full consciousness, and solid food was allowed 1 to 2 h later according to the patients' willingness. The perioperative fasting time was recorded and the patients' subjective comfort with respect to thirst and hunger was assessed using an interview-assisted questionnaire. RESULTS In total, 306 patients were enrolled in this study. The compliance rate of preoperative carbohydrate loading was 71.6%, and 93.5% of patients began ingestion of oral liquids within 2 h after surgery. The median (interquartile range) preoperative fasting time for liquids and solids was 8 (5.2-12.9) and 19 (15.7-22) hours, respectively. The median postoperative fasting time for liquids and solids was 1 (0.5-1.9) and 2.8 (2.2-3.5) hours, respectively. A total of 70.3% and 74.2% of patients reported no thirst and hunger during the perioperative period, respectively. Logistic regression analysis showed that the preoperative fasting time for liquids was an independent risk factor for perioperative hunger. No risk factor was identified for perioperative thirst. No adverse events such as aspiration pneumonia or gastroesophageal reflux were observed. CONCLUSIONS In this study of a real clinical practice setting, abbreviated perioperative fasting management was carried out with high compliance in patients with fresh fractures. The preoperative fasting time should be further shortened to further improve patients' subjective comfort.
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Affiliation(s)
- Zhi-Jian Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Xu Sun
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Yan Huo
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Meng Mi
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Gui-Ling Peng
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Chun-Ling Zhang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Yao Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Yan Zhou
- Department of Anesthesiology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Xia Zhao
- Department of Nutriology, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Ting Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China.
| | - Xin-Bao Wu
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing, 100035, China
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Lin XQ, Chen YR, Chen X, Cai YP, Lin JX, Xu DM, Zheng XC. Impact of preoperative carbohydrate loading on gastric volume in patients with type 2 diabetes. World J Clin Cases 2022; 10:6082-6090. [PMID: 35949825 PMCID: PMC9254193 DOI: 10.12998/wjcc.v10.i18.6082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/21/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery advocates that consuming carbohydrates two hours before anesthesia is beneficial to the patient's recovery. Patients with diabetes are prone to delayed gastric emptying. Different guidelines for preoperative carbohydrate consumption in patients with diabetes remain controversial due to concerns about the risk of regurgitation, aspiration and hyperglycemia. Ultrasonic gastric volume (GV) assessment and blood glucose monitoring can comprehensively evaluate the safety and feasibility of preoperative carbohydrate intake in type 2 diabetes (T2D) patients.
AIM To evaluate the impact of preoperative carbohydrate loading on GV before anesthesia induction in T2D patients.
METHODS Patients with T2D receiving surgery under general anesthesia from December 2019 to December 2020 were included. A total of 78 patients were randomly allocated to 4 groups receiving 0, 100, 200, or 300 mL of carbohydrate loading 2 h before anesthesia induction. Gastric volume per unit weight (GV/W), Perlas grade, changes in blood glucose level, and risk of reflux and aspiration were evaluated before anesthesia induction.
RESULTS No significant difference was found in GV/W among the groups before anesthesia induction (P > 0.05). The number of patients with Perlas grade II and GV/W > 1.5 mL/kg did not differ among the groups (P > 0.05). Blood glucose level increased by > 2 mmol/L in patients receiving 300 mL carbohydrate drink, which was significantly higher than that in groups 1 and 2 (P < 0.05).
CONCLUSION Preoperative carbohydrate loading < 300 mL 2 h before induction of anesthesia in patients with T2D did not affect GV or increase the risk of reflux and aspiration. Blood glucose levels did not change significantly with preoperative carbohydrate loading of < 200 mL. However, 300 mL carbohydrate loading may increase blood glucose levels in patients with T2D before induction of anesthesia.
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Affiliation(s)
- Xin-Qiang Lin
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian Maternity and Child Care Hospital, Putian 351100, Fujian Province, China
| | - Yu-Ren Chen
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian 351100, Fujian Province, China
| | - Xiao Chen
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian 351100, Fujian Province, China
| | - Yu-Ping Cai
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian 351100, Fujian Province, China
| | - Jian-Xin Lin
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian 351100, Fujian Province, China
| | - De-Ming Xu
- Department of Anesthesiology, Affiliated Hospital of Putian College, Putian 351100, Fujian Province, China
| | - Xiao-Chun Zheng
- Department of Anesthesiology, Shenli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
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Qin H, Ji J, Miao Y, Liu T, Zhao D, Jia Z, Jiang J, Liu J, Li Q, Ji X, Fu W, Lou D, Xia W, Li N. Efficacy of the Oral Administration of Maltodextrin Fructose Before Major Abdominal Surgery: A Prospective, Multicenter Clinical Study. World J Surg 2022; 46:2132-2140. [PMID: 35718790 PMCID: PMC9334424 DOI: 10.1007/s00268-022-06455-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
Background To study the efficacy of the oral administration of maltodextrin and fructose before major abdominal surgery (MAS). Methods This prospective, multicenter, parallel-controlled, double-blind study included patients aged 45–70 years who underwent elective gastrectomy, colorectal resection, or duodenopancreatectomy. The intervention group (IG) was given 800 mL and 400 mL of a maltodextrin and fructose beverage at 10 h and 2 h before MAS, respectively, and the control group (CG) received water under the same experimental conditions. The primary endpoint was insulin resistance index (IRI), and the secondary endpoints were fasting blood glucose, fasting insulin, insulin secretion index, insulin sensitivity index, intraoperative blood glucose, subjective comfort score, and clinical outcome indicators. Results A total of 240 cases were screened, of which 231 cases were randomly divided into two groups: 114 in the IG and 117 in the CG. No time-treatment effect was detected for any endpoint. The IRI and fasting insulin were significantly lower in the IG than CG after MAS (p = 0.02 & P = 0.03). The scores for anxiety, appetite, and nausea were significantly lower in the IG than CG at 1 h before MAS. Compared with baseline, the scores for appetite and nausea decreased in the IG but increased in the CG. Conclusion The oral administration of maltodextrin and fructose before MAS can improve preoperative subjective well-being and reduce postoperative insulin resistance without increasing the risk of gastrointestinal discomfort.
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Affiliation(s)
- Huanlong Qin
- Department of General Surgery, Shanghai Tenth People's Hospital, Shanghai, China
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, China
| | - Yi Miao
- Pancreas Center, Jiangsu Province Hospital, The first Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tong Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Dongbing Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Beijing, China
| | - Zhenyi Jia
- Department of General Surgery, Shanghai Tenth People's Hospital, Shanghai, China.,Department of General Surgery, Shanghai Sixth People's Hospital, Shanghai, China
| | - Jun Jiang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiang Liu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Shanghai, China
| | - Qiang Li
- Pancreas Center, Jiangsu Province Hospital, The first Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xi Ji
- Department of Gastrointestinal Surgery, Peking University Cancer Hospital, Beijing, China
| | - Weihua Fu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Donghua Lou
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wenyu Xia
- Jiangsu Chia Tai Fenghai Pharmaceutical Co. Ltd., Nanjing, Jiangsu, China
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China. .,Department of Colorectal Disease, Shanghai Tenth People's Hospital, Shanghai, China.
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Tavalaee M, Beigi E, Karbalaeikhani A, Shirzadi A, Ahmadinejad I. Evaluation of carbohydrate loading on clinical results and metabolic responses in patients undergoing laparoscopic cholecystectomy. Ann Med Surg (Lond) 2022; 78:103963. [PMID: 35734673 PMCID: PMC9207142 DOI: 10.1016/j.amsu.2022.103963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/04/2022] [Accepted: 06/05/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mahdi Tavalaee
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ehsan Beigi
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ali Karbalaeikhani
- Department of Surgery, School of Medicine, Emam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran
| | - Alireza Shirzadi
- Department of Surgery, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Izadmehr Ahmadinejad
- Student Research Committee, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author.
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Zhao S, Ling Q, Liang F, Lin Z, Deng Y, Huang S, Zhu Q. Different preoperative fluids do not affect the hemodynamic status but gastric volume: results of a randomized crossover pilot study. BMC Anesthesiol 2022; 22:158. [PMID: 35610575 PMCID: PMC9128243 DOI: 10.1186/s12871-022-01697-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/09/2022] [Indexed: 11/21/2022] Open
Abstract
Background and objective Inferior vena cava (IVC) examination has been reported as a noninvasive method for evaluating the hemodynamic state. We conducted this crossover pilot study to investigate the effects of the administration of water and high-carbohydrate-containing fluids on the hemodynamic status of volunteers through collapsibility index of IVC (IVCCI) measurement. Methods Twenty volunteers were randomly assigned to a water or high-carbohydrate group according to computer-generated random numbers in a 1:1 ratio. In the water group, volunteers received water (5 mL/kg), and in the high-carbohydrate group, patients received carbohydrate drinks (5 mL/kg). Respiratory variations in the IVC diameter, gastric volume, and blood pressure and heart rates in erect and supine positions were measured at admission (T1), 1 h (T2), 2 h (T3), 3 h (T4), and 4 h (T5). Results When considering participants with an IVCCI of more than 42%, there were no significant differences between the water and carbohydrate drink groups at each time point (all p > 0.05). At T2, more participants had an empty stomach in water group than in carbohydrate drink group (p < 0.001). At T3, 30% of the participants could not empty their stomachs in carbohydrate drink group. However, with regard to the number of volunteers with empty stomach at T3, there was no significant difference between water and carbohydrate drink group. Repeated measures data analysis demonstrated that IVCCI showed no significant differences over time (p = 0.063 for T1-T5). There were no differences between water and carbohydrate drinks (p = 0.867). Conclusion Our results suggested that neither water nor carbohydrate drinking affected the hemodynamic status through IVCCI measurement over time, up to 4 h after drinking. Furthermore, carbohydrate drinking might delay gastric emptying at 1 h, but not 2 h after drinking, in comparison with water. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01697-3.
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Affiliation(s)
- Shuhua Zhao
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, Guangdong Province, 518107, People's Republic of China.,Guangzhou Medical University, No.1 Xinzao Road, Panyu District, Guangzhou City, 511436, People's Republic of China
| | - Qiong Ling
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou City, People's Republic of China
| | - Fengping Liang
- Department of Medical Ultrasound, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen City, People's Republic of China
| | - Zhongmei Lin
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, Guangdong Province, 518107, People's Republic of China
| | - Yingqing Deng
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, Guangdong Province, 518107, People's Republic of China
| | - Shaonong Huang
- Guangzhou Medical University, No.1 Xinzao Road, Panyu District, Guangzhou City, 511436, People's Republic of China.
| | - Qianqian Zhu
- Department of Anesthesiology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen City, Guangdong Province, 518107, People's Republic of China.
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Alexander J, Castelow C, Cieker C, Wilbanks D, Asbeutah AA, Khouzam RN, Melton CD. Is NPO (Nil Per Os) order helping or hindering elective cardiac procedures? Curr Probl Cardiol 2022:101179. [PMID: 35341803 DOI: 10.1016/j.cpcardiol.2022.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
The practice of fasting before elective cardiac procedures including cardiac catheterization and transesophageal echocardiography is commonly implemented but evidence for these requirements is lacking. Fasting periods often exceed the intended length of time, increasing the risk of irritability, dehydration, acute kidney injury, hypoglycemia, and length of hospitalization. The practice of perioperative fasting relies on the premise that aspiration during general anesthesia can be mitigated by minimizing the volume of gastric contents, and stomach acidity. But the evidence has shown that fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. Elective cardiac procedures are performed using procedural sedation, where the risk of serious aspiration is small. In most patients, we argue, that strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized given the overall low risk of aspiration with elective procedures utilizing procedural sedation. In this review, we examine the historical origins and current evidence relating to the practice of fasting as it relates to cardiac catheterization and transesophageal echocardiography.
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Affiliation(s)
- John Alexander
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN.
| | | | | | - David Wilbanks
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Abdul Aziz Asbeutah
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Charles D Melton
- Baylor Scott and White Health, All Saints Medical Center, Fort Worth, TX
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Toh JWT, Collins GP, Pathma-Nathan N, El-Khoury T, Engel A, Smith S, Richardson A, Ctercteko G. Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons. Langenbecks Arch Surg 2022; 407:1637-1646. [PMID: 35275247 PMCID: PMC9283181 DOI: 10.1007/s00423-022-02488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. METHODS A questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX). RESULTS Of 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01-9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96-9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83-9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49-9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58-8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17-8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32-8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49-7.66]). CONCLUSIONS This survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.
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Affiliation(s)
- James Wei Tatt Toh
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia. .,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.
| | - Geoffrey Peter Collins
- Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Nimalan Pathma-Nathan
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
| | - Toufic El-Khoury
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Alexander Engel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Royal North Shore Hospital, Sydney, Australia
| | - Stephen Smith
- Colorectal Department, John Hunter Hospital, Newcastle, Australia
| | - Arthur Richardson
- Upper Gastrointestinal Department, Westmead Hospital, Sydney, Australia
| | - Grahame Ctercteko
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
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Impact of oral or enteral nutritional support on clinical outcomes of patients subjected to cardiac surgery: a systematic review. Clin Nutr ESPEN 2022; 49:28-39. [DOI: 10.1016/j.clnesp.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 11/24/2022]
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Kukliński J, Steckiewicz KP, Piwowarczyk SP, Kreczko MJ, Aszkiełowicz A, Owczuk R. Effect of Carbohydrate-Enriched Drink Compared to Fasting on Hemodynamics in Healthy Volunteers. A Randomized Trial. J Clin Med 2022; 11:825. [PMID: 35160276 PMCID: PMC8836957 DOI: 10.3390/jcm11030825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022] Open
Abstract
Fasting prior to surgery can cause dehydration and alter hemodynamics. This study aimed to determine the impact of a carbohydrate-enriched drink (NutriciaTM Pre-op®) on selected hemodynamical parameters, measured in a non-invasive manner. We enrolled 100 healthy volunteers and measured their weight, height, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), thoracic fluid content (TFC), thoracic fluid index (TFCI), stroke volume (SV), stroke volume variation (SVV), stroke index (SI), cardiac output (CO), cardiac index (CI), heather index (HI), systolic time ration (STR), systemic time ratio index (STRI), systemic vascular resistance (SVR), and systemic vascular resistance index (SVRI) by a Niccomo™ device, implementing the impedance cardiography (ICG) method. Measurements were performed at the beginning of the study, and after 10 h and 12 h. We randomly allocated participants to the control group and the pre-op group. The pre-op group received 400 mL of Nutricia™ preOp®, as suggested in the ERAS guidelines, within 10 h of the study. Student's t-test or the Mann-Whitney U test were used to compare the two groups, and p < 0.05 was considered significant. We did not observe any changes in hemodynamical parameters, blood pressure, and heart rate between the groups. We have proven that carbohydrate-enriched drink administration did not have a significant impact on the hemodynamical parameters of healthy volunteers.
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Affiliation(s)
- Jakub Kukliński
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland; (J.K.); (M.J.K.); (A.A.); (R.O.)
| | - Karol P. Steckiewicz
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland; (J.K.); (M.J.K.); (A.A.); (R.O.)
| | - Sebastian P. Piwowarczyk
- Students Scientific Society, Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland;
| | - Mateusz J. Kreczko
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland; (J.K.); (M.J.K.); (A.A.); (R.O.)
| | - Aleksander Aszkiełowicz
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland; (J.K.); (M.J.K.); (A.A.); (R.O.)
| | - Radosław Owczuk
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdansk, 80-210 Gdańsk, Poland; (J.K.); (M.J.K.); (A.A.); (R.O.)
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Ocón Bretón MJ, Tapia Guerrero MJ, Ramírez Rodriguez JM, Peteiro Miranda C, Ballesteros Pomar MD, Botella Romero F, Martínez Olmos MÁ, Luengo Pérez LM, Cancer Minchot E, García Malpartida K, López Gómez JJ, Zugasti Murillo A, Álvarez Hernández J, Bretón Lesmes I. Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project. ENDOCRINOL DIAB NUTR 2022; 69:98-111. [PMID: 35256065 DOI: 10.1016/j.endien.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.
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Affiliation(s)
- M Julia Ocón Bretón
- Sección de Nutrición Clínica, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
| | - M José Tapia Guerrero
- Servicio de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Malaga, Spain
| | | | - Carlos Peteiro Miranda
- Servicio de Endocrinología y Nutrición, Hospital de Viladecans, Viladecans, Barcelona, Spain
| | | | - Francisco Botella Romero
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, Spain; Comité Gestor de Área de Nutrición de la Sociedad Española de Endocrinología y Nutrición (SEEN), Spain
| | - Miguel Ángel Martínez Olmos
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Emilia Cancer Minchot
- Sección de Endocrinología y Nutrición, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain; Comité Gestor de Área de Nutrición de la Sociedad Española de Endocrinología y Nutrición (SEEN), Spain
| | - Katherine García Malpartida
- Sección de Endocrinología y Nutrición, Hospital Universitario y Politécnico la Fe, Valencia, Spain; Comité Gestor de Área de Nutrición de la Sociedad Española de Endocrinología y Nutrición (SEEN), Spain
| | - Juan José López Gómez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Comité Gestor de Área de Nutrición de la Sociedad Española de Endocrinología y Nutrición (SEEN), Spain
| | - Ana Zugasti Murillo
- Sección de Nutrición Clínica y Dietética, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain; Comité Gestor de Área de Nutrición de la Sociedad Española de Endocrinología y Nutrición (SEEN), Spain
| | - Julia Álvarez Hernández
- Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Irene Bretón Lesmes
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Li X, Liu L, Liang XQ, Li YT, Wang DX. Preoperative carbohydrate loading with individualized supplemental insulin in diabetic patients undergoing gastrointestinal surgery: A randomized trial. Int J Surg 2022; 98:106215. [PMID: 34995804 DOI: 10.1016/j.ijsu.2021.106215] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/03/2021] [Accepted: 12/18/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Preoperative carbohydrate drink is used to improve patients' comfort and recovery, but evidence remains limited in diabetic patients. Herein we investigated the effects of preoperative carbohydrate loading with individualized supplemental insulin regimen in diabetic patients undergoing gastrointestinal surgery. METHODS A total of 63 adult patients with type 2 diabetes mellitus undergoing major gastrointestinal surgery were randomized to receive either carbohydrate loading with individualized supplemental insulin (Carbohydrate group) or routine management (Control group). The primary outcome was time to first flatus after surgery. Among secondary outcomes, subjective feelings of thirsty, hunger and fatigue were assessed with the Visual Analogue Scale (scores range from 0 to 100, where 0 indicate no discomfort and 100 the most severe discomfort) before and after surgery. Adverse events were monitored until 24 h after surgery. RESULTS All patients were included in the intention-to-treat analysis. Time to first flatus did not differ between groups (median 41 h [IQR 18-69] in the Control group vs. 43 h [27-54] in the Carbohydrate group; hazard ratio 1.24 [95% CI 0.74-2.07]; P = 0.411). The VAS score of preoperative subject feeling of thirsty (median difference -33 [95% CI -50 to -15], P < 0.001), hunger (-25 [-40 to -10], P < 0.001), and fatigue (-5 [-30 to 0], P = 0.004), as well as postoperative subject feeling of thirsty (-50 [-60 to -30], P < 0.001), hunger (-20 [-40 to 0], P = 0.003), and fatigue (0 [-20 to 0], P = 0.020) were all significantly lower in the Carbohydrate group than in the Control group. Intraoperative hypotension (40.6% [13/32] vs. 16.1% [5/31], P = 0.031) and postoperative nausea and vomiting within 24 h (31.3% [10/32] vs. 9.7% [3/31], P = 0.034) occurred less in patients given carbohydrate drink. CONCLUSION In diabetic patients undergoing gastrointestinal surgery, preoperative carbohydrate loading with individualized supplemental insulin did not promote gastrointestinal recovery but improved perioperative well-being.
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Affiliation(s)
- Xue Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China Department of Endocrinology, Peking University First Hospital, Beijing, China OUTCOMES RESEARCH Consortium, Cleveland, OH, USA
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Williams DGA, Wischmeyer PE. Nutrition Status Optimization for Improved Perioperative Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00504-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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44
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Update on current enhanced recovery after surgery (ERAS) pathways for hip and knee arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth 2022; 128:434-448. [PMID: 35012741 DOI: 10.1016/j.bja.2021.12.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/03/2021] [Accepted: 12/05/2021] [Indexed: 12/12/2022] Open
Abstract
This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.
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Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
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46
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Ricci C, Ingaldi C, Alberici L, Serbassi F, Pagano N, De Raffele E, Minni F, Pironi L, Sasdelli AS, Casadei R. Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials. Clin Nutr 2021; 41:313-320. [PMID: 34999325 DOI: 10.1016/j.clnu.2021.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/29/2021] [Accepted: 12/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND & AIMS The preoperative use of carbohydrate loading (CHO) is recommended in patients undergoing abdominal surgery, even if the advantages remain debatable. The aim was to evaluate the CHO benefits in patients undergoing abdominal surgery. METHODS A systematic search of randomized clinical trials was made. A frequentist random-effects network meta-analysis was carried out, reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded the morbidity rate. The secondary endpoints were aspiration/regurgitation rates, the length of stay (LOS), the rate of postoperative nausea and vomiting (PONV), the changes (Δ) in insulin sensitivity or resistance, and the postoperative C- reactive protein (CRP) values. RESULTS CHO loading and water administration had a similar probability of being the approach with a lower morbidity rate (SUCRA = 62.4% and 64.7%). CHO and clear water also had a similar chance of avoiding the PONV (SUCRA of 80.8% and 77%). The aspiration regurgitation rate was not relevant in non-fasting patients (0.06%). CHO administration was associated with the shorter hospitalization (SUCRA 86.9%), with the best metabolic profile (SUCRA values for insulin resistance and sensitivity were 81.1% and 76%). CHO enriched was the best approach for postoperative CRP values. Preoperative fasting was the worst approach for morbidity, PONV, insulin resistance and sensitivity, and CRP (SUCRA values of 32.1%, 21.7%, 10.2%, 3.2%, and 2.0%). CONCLUSION Both preoperative CHO loading and clear water use were superior to the fasting about morbidity. CHO drinks use could provide specific advantages, reduce the PONV rate, and improve carbohydrate homeostasis, inflammatory pathway, and hospitalization.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy.
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
| | - Francesco Serbassi
- Grad Student in Biology of the Health Faculty, Alma Mater Studiorum, University of Bologna, Italy
| | - Nico Pagano
- Division of Gastroenterology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Emilio De Raffele
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
| | - Loris Pironi
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit, Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Anna Simona Sasdelli
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy; Clinical Nutrition and Metabolism Unit, Centre for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Via Albertoni 15, Italy; Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy
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47
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Rollins KE, Lobo DN, Joshi GP. Enhanced recovery after surgery: Current status and future progress. Best Pract Res Clin Anaesthesiol 2021; 35:479-489. [PMID: 34801211 DOI: 10.1016/j.bpa.2020.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.
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Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Wells CI, Bhat S, Paskaranandavadivel N, Lin AY, Vather R, Varghese C, Penfold JA, Rowbotham D, Dinning PG, Bissett IP, O'Grady G. Potential causes of the preoperative increase in the rectosigmoid cyclic motor pattern: A high-resolution manometry study. Physiol Rep 2021; 9:e15091. [PMID: 34837672 PMCID: PMC8627120 DOI: 10.14814/phy2.15091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background Cyclic motor patterns (CMPs) are the most common motor pattern in the distal colon. This study used high‐resolution (HR) colonic manometry to quantify trends in distal colonic motor activity before elective colonic surgery, determine the effect of a preoperative carbohydrate load, and compare this with a meal response in healthy controls. Methods Fiber‐optic HR colonic manometry (36 sensors, 1 cm intervals) was used to investigate distal colonic motor activity in 10 adult patients prior to elective colonic surgery, 6 of whom consumed a preoperative carbohydrate drink (200 kCal). Data were compared with nine healthy volunteers who underwent HR colonic manometry recordings while fasted and following a 700 kCal meal. The primary outcome was the percentage of recording occupied by CMPs, defined as propagating contractions at 2–4 cycles per minute (cpm). Secondary outcomes included amplitude, speed, and distance of propagating motor patterns. Results The occurrence of CMPs progressively increased in time periods closer to surgery (p = 0.001). Consumption of a preoperative drink resulted in significantly increased CMP occurrence (p = 0.04) and propagating distance (p = 0.04). There were no changes in amplitude or speed of propagating motor patterns during the preoperative period. The increase in activity following a preoperative drink was of similar magnitude to the colonic meal response observed in healthy controls, despite the lesser caloric nutrient load. Conclusion Distal colonic CMP increased in occurrence prior to surgery, amplified by ingestion of preoperative carbohydrate drinks. We hypothesize that anxiety, which is also known to rise with proximity to surgery, could play a contributing role.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Sameer Bhat
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Anthony Y Lin
- Department of General Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Ryash Vather
- Department of Colorectal Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - James A Penfold
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - David Rowbotham
- Department of Gastroenterology and Hepatology, Auckland District Health Board, Auckland, New Zealand
| | - Phil G Dinning
- Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia.,Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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49
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Robinson KN, Cassady BA, Hegazi RA, Wischmeyer PE. Preoperative carbohydrate loading in surgical patients with type 2 diabetes: Are concerns supported by data? Clin Nutr ESPEN 2021; 45:1-8. [PMID: 34620304 DOI: 10.1016/j.clnesp.2021.08.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 12/17/2022]
Abstract
Currently, there is a lack of consensus on the provision of preoperative carbohydrate loading in patients with type 2 diabetes mellitus (T2DM) due to theoretical concerns including the possibility of delayed gastric emptying, perioperative hyperglycemia, and poor surgical outcomes. This narrative review summarizes the accumulating evidence on preoperative carbohydrate loading in this population and whether these concerns are supported by preliminary evidence. In general, the available research suggests that carbohydrate loading may be implemented in those with T2DM without increased risk for intra- and postoperative hyperglycemia or surgical complications. However, there is strong justification for future research to definitively study this highly debated and timely topic. Ultimately, the inclusion of preoperative carbohydrate loading for surgical patients with DM should be guided by the surgical team's clinical judgment and individualized based on patient needs and characteristics.
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Affiliation(s)
- Katie N Robinson
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Bridget A Cassady
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Refaat A Hegazi
- Scientific and Medical Affairs, Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219 USA.
| | - Paul E Wischmeyer
- Duke University School of Medicine, Department of Anesthesiology and Surgery, Center for Perioperative Organ Protection (CPOP), DUMC, Box 3094 Mail # 41, 2301 Erwin Road, 5692 HAFS, Durham, NC, 27710 USA.
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50
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Ljungqvist O, de Boer HD, Balfour A, Fawcett WJ, Lobo DN, Nelson G, Scott MJ, Wainwright TW, Demartines N. Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review. JAMA Surg 2021; 156:775-784. [PMID: 33881466 DOI: 10.1001/jamasurg.2021.0586] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion. Observations Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS. Conclusions and Relevance To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.
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Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University School of Health and Medical Sciences, Örebro, Sweden
| | - Hans D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
| | - Angie Balfour
- Surgical Services, NHS [National Health Service] Lothian, Edinburgh, United Kingdom
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC (Medical Research Council) Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham School of Life Sciences, Queen's Medical Centre, Nottingham, United Kingdom
| | - Gregg Nelson
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, United Kingdom
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
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