Preoperative carbohydrate loading before colorectal surgery: a systematic review and meta-analysis of randomized controlled trials

Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 1)-2025 update

BACKGROUND

Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.

METHODS

Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).

CONCLUSION

The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome.

Different regimens of preoperative carbohydrate loading on insulin resistance: A network meta-analysis

BACKGROUND & AIMS

The effectiveness of preoperative carbohydrate loading(PCL) on postoperative insulin resistance(IR) is controversial. In addition, the effect of different doses of carbohydrates on postoperative IR is also controversial. Therefore, this study aimed to investigate the efficiency of PCL on postoperative IR and the optimal regimen for the effect on postoperative IR.

METHODS

A systematic search of clinical randomized controlled trials was performed to extract basic information about the included studies, specific regimens of PCL, and preoperative and postoperative IR. Network meta-analysis was performed using frequentist random effects. A total of 7 regimens were identified by categorizing them based on frequency, timing, control groups, and conducting subgroup analysis according to surgical procedure. High (>45 g) and low (≤45 g) doses were divided according to the standard definition of PCL. Dose analysis was performed on studies in the subgroups that met the optimal frequency and timing regimen. Reporting of results based on weighted mean differences(WMD), 95 % confidence intervals(95%CrI), and the surface under the cumulative ranking(SUCRA).

RESULTS

Carbohydrate loading given only 3 h before surgery is more strongly associated with insulin resistance than fasting(WMD: -4.04,95%CrI: -5.67 to -2.40) and placebo(WMD: -4.00,95%CrI: -5.98 to -2.02). Single-dose preoperative 3 h regimen has the highest probability of being the optimal regimen(SUCRA = 90.9 %). This is also true in open(SUCRA = 93.7 %) and laparoscopic surgery(SUCRA = 99.9 %). Analyzed using a fixed-effects model in open and laparoscopic surgery. In open surgery, high-dose and low-dose carbohydrates are associated with postoperative IR compared with fasting(high-dose: WMD: -1.75,95%CrI: -1.95 to -1.54; low-dose: WMD: -2.46,95%CrI: -3.70 to -1.23) and placebo(high-dose: WMD: -5.37,95%CrI: -6.99 to -3.76; low-dose: WMD: -6.09,95%CrI: -7.29 to -4.90). Low-dose carbohydrates(SUCRA = 95.3 %) have the highest probability of being the best option. In laparoscopic surgery, high-dose and low-dose carbohydrates are also associated with postoperative IR compared with fasting(high-dose (WMD: -5.70,95 %, CrI: -7.63 to -3.77); low-dose (WMD: -3.69,95%CrI: -4.11 to -3.27))and placebo(high-dose (WMD: -5.73,95%CrI: -7.72 to -3.74); low-dose (WMD: -3.72,95%CrI: -4.14 to -3.30)). SUCRA for high-dose carbohydrates is 99.2 %.

CONCLUSION

Preoperative implementation of carbohydrate loading is more beneficial in alleviating postoperative insulin resistance than fasting and placebo. Conducting PCL on the morning of surgery is more effective in relieving postoperative IR. For both open and laparoscopic surgeries, administering carbohydrate loading 3 h before the surgery may represent the optimal regimen. Further studies are needed to investigate the effect of different doses on postoperative IR.

Effect of preoperative oral carbohydrate loading on postoperative insulin resistance, patient-perceived well-being, and surgical outcomes in elective colorectal surgery: a randomized controlled trial

BACKGROUND

Insulin resistance (IR) is one of the independent determinants influencing the length of hospital stay (LOHS) and postoperative complications in colorectal procedures. Preoperative oral carbohydrate loading (OCL) has emerged as a prospective countermeasure for IR. This study aimed to investigate the effects of preoperative carbohydrate loading on postoperative IR, inflammatory parameters, and clinical outcomes in patients undergoing elective colorectal surgery.

METHODS

This was an open-label, parallel arm, superiority randomized controlled trial conducted over 2 years. Participants were assigned to conventional fasting and oral OCL groups. IR, insulin sensitivity, Glasgow Prognostic Score (GPS), and interleukin 6 levels were analyzed on the day of surgery and on the first postoperative day (POD-1) and third POD (POD-3). Clinical parameters, such as thirst, hunger, dry mouth, anxiety, weakness, pain, nausea, and vomiting, were compared in the perioperative period. In addition, surgical clinical outcomes, such as intestinal recovery, time to independent ambulation, postoperative morbidity, and LOHS, were studied.

RESULTS

A total of 72 participants were included, with 36 in each group. In the OCL group, there was a statistically significant decrease in postoperative IR on the day of surgery, POD-1, and POD-3 (P = .0336). Similarly, inflammatory parameters and the GPS were found to be significantly lower in the OCL group (P < .001). Clinical parameters, such as thirst, hunger, and dry mouth, were significantly lower in the intervention group (P =.00), with a shortened LOHS.

CONCLUSION

This study demonstrated that preoperative carbohydrate loading is associated with reduced IR and inflammatory markers, shortened hospital stays, and improved overall clinical outcomes in elective colorectal surgery.

Pathophysiology and Management of Postoperative Ileus in Adults and Neonates: A Review

Postoperative ileus (POI) is caused by enteric neural dysfunction and inflammatory response to the stress of surgery as well as the effect of anesthetics and opioid pain medications. POI results in prolonged hospital stays, increased medical costs, and diminished enteral nutrition, rendering it a problem worth tackling. Many cellular pathways are implicated in this disease process, creating numerous opportunities for targeted management strategies. There is a gap in the literature in studies exploring neonatal POI pathophysiology and treatment options. It is well known that neonatal immune and enteric nervous systems are immature, and this results in gut physiology which is distinct from adults. Neonates undergoing abdominal surgery face similar surgical stressors and exposure to medications that cause POI in adults. In this review, we aim to summarize the existing adult and neonatal literature on POI pathophysiology and management and explore applications in the neonatal population.

Effects of Preoperative Oral Carbohydrate on Perioperative Maternal Outcomes Undergoing Cesarean Section: A Systematic Review and Meta-Analysis

Purpose

Preoperative oral carbohydrate (CHO) is a rapid postoperative rehabilitation protocol that improves perioperative outcomes and is widely used in adult surgical patients. However, pregnant women are excluded because of the possibility of aspiration due to delayed gastric emptying. This meta-analysis was conducted to evaluate the efficacy of preoperative oral CHO in elective cesarean section.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to July 2023. Randomized controlled trials were included. The risk of bias was assessed using the Cochrane tool. Risk ratios and 95% confidence intervals were calculated. Meta-analysis was performed using random-effects models to estimate risk ratios and mean differences (MDs) with 95% confidence intervals (CIs). The outcomes included thirst and hunger scores, incidence of vomiting and nausea, time to flatus, and homeostatic model assessment of insulin resistance (HOMA-IR).

Results

A total of nine studies with 1211 patients were included in the analysis. The levels of thirst and hunger were evaluated using a 10-point visual analog scale, with 0 representing the best and 10 representing the worst. The severity of hunger (weighted mean difference (WMD: -2.34, 95% CI: -3.13 to -1.54), time to flatus (WMD: -3.51 hours, 95% CI: -6.85 to -0.17), and HOMA-IR (WMD: -1.04, 95% CI: -1.31 to -0.77) were significantly lower in the CHO group compared to the control group. However, there were no significant differences in the severity of thirst or the incidence of vomiting and nausea between the CHO and control groups.

Conclusion

Preoperative oral CHO during cesarean section alleviates thirst and hunger, shortens the time of postoperative flatus, and reduces HOMA-IR. However, the available evidence is insufficient to reach a clear consensus on the benefits or harms of preoperative oral CHO during cesarean section. Therefore, it is premature to make a definitive recommendation for or against its routine use.

[Clinical efficacy of carbohydrate preloading in reconstructive esophageal surgery]

OBJECTIVE

To evaluate clinical efficacy of preoperative carbohydrate loading as a component of ERAS in esophageal reconstructive surgery.

MATERIAL AND METHODS

Post hoc analysis included 162 patients who underwent esophageal reconstructive interventions with ERAS principles between 2014 and 2024. The main group (n=61, CHO+) included patients who were metabolically loaded with carbohydrates in preoperative period with 12.5% maltodextrin solution 800 mL the day before and 400 mL 2 hours before surgery per os or enterally. The control group consisted of patients without carbohydrate load (n=101, CHO-). Primary endpoint was length of hospital-stay, secondary control points - postoperative glycemia and complication rate.

RESULTS

Both groups were comparable in sex, age, character of the main and comorbid diseases, body mass index. Patients with CHO had significant lower incidence of respiratory complications (p=0.034). Both groups did not differ in the incidence of anastomosis failure, morbidity and mortality.

CONCLUSION

Preoperative carbohydrate loading in esophageal reconstructive surgery positively affects metabolic status and reduces the incidence of respiratory complications without effect on length of hospital-stay.