Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials

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

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.

Effects of Preoperative Oral Carbohydrates on Recovery After Laparoscopic Cholecystectomy: A Meta-analysis of Randomized Controlled Trials

PURPOSE

The objective of this meta-analysis was to evaluate the efficacy of administering preoperative oral carbohydrates (CHO) compared to a control treatment in improving postoperative recovery outcomes for patients undergoing laparoscopic cholecystectomy (LC).

DESIGN

A meta-analysis of randomized controlled trials.

METHODS

Through systematic searches in PubMed, Embase, and the Cochrane Library, randomized controlled trials focusing on preoperative oral carbohydrates for patients undergoing LC were collected. Data analysis was conducted using the Revman 5.3 software.

FINDINGS

The meta-analysis incorporated 19 randomized studies, with a total of 1,568 participants. Meta-analysis results indicated that patients receiving CHO reported notably lower postoperative pain compared to those fasting (P = .006) or on placebo (P = .003). Furthermore, a significant reduction in preoperative hunger was observed in the CHO group compared to the controls (P = .002). A notable difference was also identified in the postoperative Homeostasis Model Assessment-IR changes between the CHO and control groups (P = .02). No significant variations were observed in thirst, postoperative nausea and vomiting, insulin level alterations, glucose level changes, duration of hospital stay, or recovery quality.

CONCLUSIONS

Preoperative oral carbohydrates may alleviate hunger and pain, and attenuate postoperative insulin resistance more effectively than either overnight fasting or placebo in patients undergoing LC.

Impact of preoperative carbohydrate loading on postoperative course and morbidity in debulking surgery for epithelial ovarian cancer

Despite the theoretical benefits, the favorable effect of preoperative carbohydrate loading on postoperative morbidity remains controversial. Most of the outcomes reported in the literature are derived from non-gynecologic surgery data, with only one study involving a limited number of patients specifically in gynecological oncology. The present study aimed to investigate the impact of carbohydrate loading, as a single element of enhanced recovery after surgery protocols, on postoperative course and morbidity in patients undergoing debulking surgery for epithelial ovarian cancer (EOC). The present study was a non-randomized, prospective cohort trial enrolling patients with EOC who underwent surgery between June 2018 and December 2021. An oral carbohydrate supplement with a dose of 50 g was given to patients 2-3 h before anesthesia. Data on postoperative course and morbidity were collected and compared with data of a historical cohort including consecutive patients who underwent surgery without a carbohydrate loading between January 2015 and June 2018. Analyses were performed on a total of 162 patients, including 72 patients in the carbohydrate loading group and 90 patients in the control group. Median length of hospital stay (11 days vs. 11 days; P=0.555), postoperative days 1-7 serum c-reactive protein levels (P=0.213), 30-day readmission (11.6% vs. 11.5%, P=0.985), 30-day relaparotomy (2.8% vs. 3.4%, P=0.809) and 30-day morbidity (48.6% vs. 46.7%; P=0.805) were comparable between the cohorts. No significant differences in grades of morbidities were identified between the cohorts (P=0.511). Multivariate analysis revealed that the sole independent risk factor for any postoperative morbidity was operative time. In conclusion, based on the results of the present study, postoperative course and morbidity seemed to be unaffected by carbohydrate loading in patients undergoing debulking surgery for EOC.

Modern fluid management in thoracic surgery

PURPOSE OF REVIEW

To provide an approach to perioperative fluid management for lung resection patients that incorporates the entire patient pathway in the context of international guidelines on enhanced recovery after surgery (ERAS).

RECENT FINDINGS

The concern with intraoperative fluid management is that giving too little or too much fluid is associated with worse outcomes after lung resection. However, it has not emerged as a key care element in thoracic ERAS programs probably due to the influence of other ERAS elements. Carbohydrate loading 2 h before surgery and the allowance of water until just prior to induction ensures the patient is both well hydrated and metabolically normal when they enter the operating room. Consequently, maintaining a euvolemic state during anesthesia can be achieved without goal-directed fluid therapy despite the recommendations of some guidelines. Intravenous fluids can be safely stopped in the immediate postoperative period.

SUMMARY

The goal of perioperative euvolemia can be achieved with the ongoing evolution and application of ERAS principles. A focus on the pre and postoperative phases of fluid management and a pragmatic approach to intraoperative fluid management negates the need for goal-directed fluid therapy in most cases.

Effects of caloric and nutrient content of oral fluids on gastric emptying in volunteers: a randomised crossover study

BACKGROUND

Previous studies demonstrated conflicting results regarding the determinants of gastric emptying for fluids. Our aim was to compare gastric emptying times of fluids with different caloric and nutrient content.

METHODS

Healthy adult volunteers underwent gastric ultrasound assessment for 4 h after consuming beverages with different caloric and nutrient content using a crossover design (oat drink with 3% fat [310 kcal], mango juice [310 kcal], oat drink with 0.5% fat [185 kcal], and blackcurrant juice [175 kcal]). Gastric emptying time, gastric content volume, and the area under the curve (AUC) of gastric content volume-time profiles were calculated.

RESULTS

Eight females and eight males completed the study protocol. The mean (sd) gastric emptying times were 89 (32) min for blackcurrant juice, 127 (54) min for oat drink with 0.5% fat, 135 (36) min for mango juice, and 152 (40) min for oat drink with 3% fat. Gastric emptying times were slower for oat drink with 3% fat (P=0.007) and mango juice (P=0.025) than for blackcurrant juice. At 1 h after ingestion, gastric content volume was greater for mango juice (P=0.021) and oat drink with 3% fat (P=0.003) than for blackcurrant juice. The AUC was greater for oat drink with 3% fat than mango juice (P=0.029), oat drink with 0.5% fat (P=0.004), and blackcurrant juice (P=0.002), and for mango juice than blackcurrant juice (P=0.019).

CONCLUSIONS

Caloric and nutrient content significantly affected gastric emptying times. A high-calorie fruit juice (mango) exhibited delayed emptying times compared with a low-calorie fruit juice (blackcurrant).

CLINICAL TRIAL REGISTRATION

ISRCTN17147574.

Validation of a popsicle as a clear fluid to abbreviate preoperative fasting

BACKGROUND & AIMS

This study is based on the development and validation of a popsicle to reduce preoperative fasting time.

METHODS

The study was carried out in two stages, pre-clinical and clinical validation. The first stage consisted of producing a water-based, fat-free, high-calorie fruit-flavored popsicle, characterized by proximal composition and sensory analysis. In the second stage, clinical validation was performed in patients aged between 18 and 65 years before elective surgery, evaluating the incidence of aspiration during anesthesia and the patient's experience in relation to hunger, thirst, anxiety and palatability of the popsicle.

RESULTS

The results of the study showed that the use of popsicle 2 h before the surgical procedure did not cause any adverse reaction in patients and in the anesthetic procedure. Furthermore, the full acceptability of the product by the participants and the control of thirst and satiety during the preoperative period were observed.

CONCLUSIONS

The present study showed that with the use of popsicles it was possible to reduce safely the preoperative fasting time to up to 2 h before the surgical procedure.

Metabolic effects of an oral carbohydrate-whey protein supplement after fasting in volunteers: A randomized controlled crossover trial

OBJECTIVE

Oral supplements containing carbohydrates (CHOs) can be used to reduce preoperative fasting time. The aim of this study was to investigate the early metabolic and acute phase responses to a clear, oral supplement containing CHO and whey protein (WP) in young, healthy volunteers during a fasting-induced organic response.

METHODS

In this controlled crossover clinical trial, volunteers were randomized into groups after a 12-h fast: the CHO+WP group consumed 200 mL CHO enriched with WP (n = 30); the CHO group members consumed 200 mL water plus maltodextrin (n = 30), and the Fast group was fasted only (n = 30). Blood samples were collected after fasting and 3 h after ingestion of the supplement. The samples were analyzed for glucose, glycated hemoglobin, insulin, C-reactive protein, β-hydroxybutyrate, triacylglycerols, albumin, chlorine, and sodium. After 7 d, the groups were inverted, so all volunteers entered the three groups.

RESULTS

The nutritional intervention did not change the biochemical parameters related to the acute phase response or insulin resistance; however, there was a statistically significant reduction (P < 0.001) in serum β-hydroxybutyrate in the CHO+WP group (0.05 ± 0.08 mmol/L) compared with the other two groups (Fast group: 0.11 ± 0.08 mmol/L; CHO group: 0.09 ± 0.13 mmol/L).

CONCLUSIONS

After overnight fasting, the oral supplement containing CHO and WP decreased ketosis. These findings may help select the most efficient oral supplement to be given 2 to 3 h before elective surgeries.

Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery

Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.

Efficacy analysis of enhanced recovery after surgery in laparoscopic-assisted radical resection of type I choledochal cyst

Objective

The objective of this study was to investigate the feasibility and effectiveness of laparoscopic-assisted radical resection of type I choledochal cyst (CC) guided by the principles of enhanced recovery after surgery (ERAS).

Methods

A retrospective cohort study of type I CC admitted to our hospital between May 2020 and December 2021 were analyzed, a total of 41 patients with choledochal cyst underwent surgery during this period and 30 cases were selected based on inclusion and exclusion criteria. Patients (n = 15) who received the traditional treatment from May 2020 to March 2021 were included in the traditional group. Patients (n = 15) who received ERAS from April 2021 to December 2021 were included in the ERAS group. Both groups underwent surgery performed by the same surgical team. Preoperative data of the two groups were recorded, and relevant data were statistically analyzed and compared.

Results

There was a statistically significant difference in the dose of opioids. Significant differences were observed between the ERAS and traditional groups in the results of the FLACC pain assessment scale on the 1st and 2nd day after surgery, time of gastric tube, urinary catheter and abdominal drainage tube removal, time of first defecation after operation, time of first eating after operation, time to reach full food intake, results of CRP, ALB, and ALT on the 3rd and 7th postoperative day, postoperative hospital stay, and total treatment cost. No significant differences were observed between the two groups in terms of gender, age, body weight, cyst size, preoperative CRP, ALB, ALT, intraoperative blood loss, operation time, and the number of cases converted to laparotomy. Neither the FLACC pain assessment scale on the 3rd day after surgery, the incidence of postoperative complications, nor the rate of readmission within 30 days showed significant differences.

Conclusions

Laparoscopic-assisted radical resection of type I CC guided by the principles of ERAS is safe and effective for children. The ERAS concept demonstrated advantages over traditional laparoscopic surgery, including reduced opioid use, shorter time to first postoperative defecation, earlier resumption of postoperative feeding, shorter time to reach full feeding, shorter postoperative hospital stay, and lower total treatment cost.

Preoperative carbohydrate load to reduce perioperative glycemic variability and improve surgical outcomes: A scoping review

The detrimental effects of both diabetes mellitus (DM) and hyperglycemia in the perioperative period are well established and have driven extensive efforts to control blood glucose concentration (BGC) in a variety of clinical settings. It is now appreciated that acute BGC spikes, hypoglycemia, and high glycemic variability (GV) lead to more endothelial dysfunction and oxidative stress than uncomplicated, chronically elevated BGC. In the perioperative setting, fasting is the primary approach to reducing the risk for pulmonary aspiration; however, prolonged fasting drives the body into a catabolic state and therefore may increase GV. Elevated GV in the perioperative period is associated with an increased risk for postoperative complications, including morbidity and mortality. These challenges pose a conundrum for the management of patients typically instructed to fast for at least 8 h before surgery. Preliminary evidence suggests that the administration of an oral preoperative carbohydrate load (PCL) to stimulate endogenous insulin production and reduce GV in the perioperative period may attenuate BGC spikes and ultimately decrease postoperative morbidity, without significantly increasing the risk of pulmonary aspiration. The aim of this scoping review is to summarize the available evidence on the impact of PCL on perioperative GV and surgical outcomes, with an emphasis on evidence pertaining to patients with DM. The clinical relevance of GV will be summarized, the relationship between GV and postoperative course will be explored, and the impact of PCL on GV and surgical outcomes will be presented. A total of 13 articles, presented in three sections, were chosen for inclusion. This scoping review concludes that the benefits of a PCL outweigh the risks in most patients, even in those with well controlled type 2 DM. The administration of a PCL might effectively minimize metabolic derangements such as GV and ultimately result in reduced postoperative morbidity and mortality, but this remains to be proven. Future efforts to standardize the content and timing of a PCL are needed. Ultimately, a rigorous data-driven consensus opinion regarding PCL administration that identifies optimal carbohydrate content, volume, and timing of ingestion should be established.

Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update

BACKGROUND

Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges.

METHODS

Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.

Residual gastric volume after 3 h of the ingestion of an oral supplement containing carbohydrates alone or associated with whey protein: a randomized crossover pilot study

BACKGROUND

New formulas including a nitrogenous source to maltodextrin have been reported as preoperative beverages 2-3 h before anesthesia in the elective procedure. Whey protein is a potential candidate for the composition of this clear oral supplement. This study aimed to investigate the gastric residual volume (GRV) of healthy volunteers 3 h after the ingestion of an oral supplement containing carbohydrates (CHO) alone or combined with whey protein (WP).

METHODS

This crossover clinical trial design includes young, healthy male volunteers with normal body mass index. Magnetic resonance imaging (MRI) scan of the upper abdomen to measure the GRV was performed in the participants in three phases: (1) after a fasting period of 8 h; (2) immediately after the ingestion of 200 mL of a clear supplement containing: (2a) 10 g of WP and 54 g of CHO (74% glucose and 26% maltodextrin)-WP + CHO group or (2b) 12.5% maltodextrin (25 g)-CHO group; and (3) after 3 h of the ingestion of both types of supplements. A week interval was programmed between phases 2a and 2b.

RESULTS

There was no significant difference (p = 0.91; within-group comparison) of the mean ± SD of the GRV between phase 1 (WP + CHO: 23.45 ± 14.01; CHO: 25.03 ± 15.17 cm³; p = 0.78; between-groups comparison) and phase 3 (WP + CHO: 25.66 ± 9.31; CHO: 23.45 ± 13.58 cm³, p = 0.86; between-groups comparison). The GRV of phase 2 (WP + CHO: 206.43 ± 23; CHO: 203.99 ± 12.18 cm³; p = 0.82; between-groups comparison) was significantly greater (p < 0.01; within-group comparison) than both other two phases.

CONCLUSION

The GRV after 3 h of the ingestion of either WP + CHO or CHO oral supplement returns to basal fast condition implying that gastric emptying after this interval of time is significantly completed.

TRIAL REGISTRATION

Registered and posted on the ClinicalTrials.gov public website with Identifier: NCT05573854.

Extending the benefit of nutrition intervention beyond the operative setting

PURPOSE OF REVIEW

To provide an update of the recent evidence on the potential of perioperative nutritional interventions to benefit adult patients undergoing head and neck and digestive procedures.

RECENT FINDINGS

Perioperative nutrition within multimodal prehabilitation programs improve postoperative outcomes. Perioperative fasting time can be reduced with beverages containing carbohydrate alone or blended with a nitrogenous source such as whey protein; this approach seems to be safe and improve outcome. The choice of protein-containing formula, as well as diet composition to be recommended early during the postoperative refeeding, can be optimized to reduce complications. Sarcopenia is an important risk factor for surgical patients, as such, prehabilitation along with preoperative nutrition is strongly advised. Perioperative supplementation with β-hydroxy β-methylbutyrate to mitigate sarcopenia requires further investigation. Although perioperative nutritional interventions reduce healthcare costs, recent data suggest it has been scarcely prescribed.

SUMMARY

Nutritional intervention is key in multimodal programs of enhanced recovery after surgery to ensure better outcomes. Perioperative fasting should be shortened, and include clear fluids containing carbohydrates and protein, especially in the early postoperative period. Multimodal prehabilitation is key to mitigate sarcopenia. Action to improve knowledge on the cost-effectiveness of nutritional interventions in the perioperative setting are needed.

Effects of Preoperative Oral Electrolyte-Carbohydrate Nutrition Supplement on Postoperative Outcomes in Elderly Patients Receiving Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Objective

Patients undergoing total knee arthroplasty (TKA) were primarily geriatric, with high risk of postoperative electrolyte disorders and malnutrition. Randomized controlled trials regarding oral nutrition supplement (ONS) strategies in TKA was sparse. This study aimed to evaluate the efficacy of preoperative oral electrolyte‐carbohydrate nutrition supplement (OECNS) on patients (aged >65 years) undergoing TKA.

Methods

From April 2019 to January 2020, 94 patients undergoing primary elective unilateral TKA in our hospital were considered in this prospective randomized controlled study. This study included patients aged over 65 years with ASA I‐III, and excluded patients with electrolyte disorders, malnutrition, and comorbidities. The control group (control group) received meal nutrition supplements (preoperative 6 h [Pre 6h]) and water (Pre 2h), while OECNS group (intervention group) received meal nutrition supplements (Pre 6h) and OECNS (Pre 2). The Student's t test and χ² test was used. The primary outcomes were the patient‐reported comfort indicators (PRCIs) including hunger, thirst, nausea, vomiting, weakness, pain, anxiety, and general comfort. The secondary outcomes included indicators of electrolyte, nutrition, functional scores, clinical results, and complications.

Results

The scores of preoperative hunger (0.43 ± 0.10), pain (2.30 ± 0.34), and anxiety (9.04 ± 2.71) were significantly lower in OECNS group compared with control group (hunger, 1.19 ± 0.21; pain, 3.79 ± 0.26; anxiety, 11.21 ± 3.02) (Pre 1h) (all p < 0.05) as well as the weakness score on the first postoperative day (POD1) (OECNS group 3.57 ± 0.24; control group 5.15 ± 0.29; p < 0.001). A higher level of Na + (OECNS group 140.54 ± 3.39; control group 138.07 ± 5.21; p = 0.008) and a reduced rate of hyponatremia (OECNS group 6.4%; control group 21.3%; p = 0.036) on POD1 were found. Moreover, the higher level of blood glucose (Post 2h) and reduced rates of abnormal blood glucose (Pre 2h, Post 6h) were verified in control group (all p < 0.05). There was no significant difference regarding the other outcomes.

Conclusion

The administration of OECNS significantly improved subjective comfort, electrolytes, and blood glucose without increasing the rates of complications in patients (aged over 65 years) undergoing TKA.